Healthcare Provider Details

I. General information

NPI: 1700332251
Provider Name (Legal Business Name): KYLE EAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 W PIERSON RD
FLUSHING MI
48433-2411
US

IV. Provider business mailing address

10174 GLENDALE AVE
CLIO MI
48420-1608
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-7896
  • Fax:
Mailing address:
  • Phone: 810-422-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004674
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: