Basic Information
| Provider Information | |||||||||
| NPI: | 1871072157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOUNT | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | AVERY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2714 W OXFORD LOOP | ||||||||
| Address2: | STE 164 | ||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 105B QUALITY LN | ||||||||
| Address2: | |||||||||
| City: | SENATOBIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386682317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625629977 | ||||||||
| FaxNumber: | 6625629978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6540 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.