Healthcare Provider Details

I. General information

NPI: 1619519725
Provider Name (Legal Business Name): KYLE BRUNSMANN MSR, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 LEBANON AVE
BELLEVILLE IL
62220-4124
US

IV. Provider business mailing address

2706 E MAIN ST
BELLEVILLE IL
62221-5034
US

V. Phone/Fax

Practice location:
  • Phone: 618-619-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.020355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: