Healthcare Provider Details

I. General information

NPI: 1881919173
Provider Name (Legal Business Name): KYLE WELLS RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 LITTLE RIVER RD
GRAYSON KY
41143-6001
US

IV. Provider business mailing address

124 LITTLE RIVER RD
GRAYSON KY
41143-6001
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-7939
  • Fax:
Mailing address:
  • Phone: 606-474-7939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number11048
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: