MEDICARE: DR. KYLE ROBERT FAIRLESS O.D.

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	152W00000X	Optometrist	4901003708	MI

General Provider Information

NPI Number	:	1912062654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE ROBERT FAIRLESS O.D.

Provider Business Mailing Address
First Line	:	3160 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5040
Country	:	US
Telephone Number	:	248-853-4141
Fax Number	:	248-853-1641

Provider Business Practice Location Address
First Line	:	3160 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5040
Country	:	US
Telephone Number	:	248-853-4141
Fax Number	:	248-853-1641

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	09/04/2025

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