Healthcare Provider Details

I. General information

NPI: 1780190181
Provider Name (Legal Business Name): BRENDAN BOYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NORMAL AVE
KIRKSVILLE MO
63501-4200
US

IV. Provider business mailing address

3666 CHANEY CT
SAINT LOUIS MO
63114-4101
US

V. Phone/Fax

Practice location:
  • Phone: 660-785-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: