Healthcare Provider Details

I. General information

NPI: 1093846305
Provider Name (Legal Business Name): KYLE WITKEMPER ATC.,LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 E STATE ROAD 44 STE A
SHELBYVILLE IN
46176-4030
US

IV. Provider business mailing address

7329 POPPYSEED DR
INDIANAPOLIS IN
46237-3675
US

V. Phone/Fax

Practice location:
  • Phone: 317-392-5855
  • Fax:
Mailing address:
  • Phone: 317-889-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000688A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: