MEDICARE: MR. KYLE WILLIAM CANAVALLY JR. ATC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	004413	NY

General Provider Information

NPI Number	:	1467172205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE WILLIAM CANAVALLY JR. ATC.

Provider Business Mailing Address
First Line	:	350 NEW CAMPUS DR
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-2914
Country	:	US
Telephone Number	:	585-395-5374
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 NEW CAMPUS DR
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-2914
Country	:	US
Telephone Number	:	585-395-5374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2022
Last Update Date	:	08/31/2022

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