Healthcare Provider Details

I. General information

NPI: 1932587961
Provider Name (Legal Business Name): KYLE FROEBER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16791 JALISCO TER W
LAKEVILLE MN
55044-5568
US

IV. Provider business mailing address

16791 JALISCO TERR. W
LAKEVILLE MN
55044
US

V. Phone/Fax

Practice location:
  • Phone: 952-607-7300
  • Fax:
Mailing address:
  • Phone: 952-607-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: