Healthcare Provider Details

I. General information

NPI: 1225498777
Provider Name (Legal Business Name): KYLE COWARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 S OGLESBY AVE APT 3B
CHICAGO IL
60649-1827
US

IV. Provider business mailing address

6901 S OGLESBY AVE APT 3B
CHICAGO IL
60649-1827
US

V. Phone/Fax

Practice location:
  • Phone: 773-610-0739
  • Fax:
Mailing address:
  • Phone: 773-610-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberC630-5017-7015
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: