Healthcare Provider Details

I. General information

NPI: 1750929220
Provider Name (Legal Business Name): KINETIC HEALTH AND PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 N ILLINOIS ST
FAIRVIEW HEIGHTS IL
62208-2700
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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KYLE BRUNSMANN
Title or Position: SPORTS THERAPIST / FUNCTIONAL REHAB
Credential: LMT, MSR
Phone: 618-619-8200