Healthcare Provider Details

I. General information

NPI: 1285901835
Provider Name (Legal Business Name): KYLE TIGNER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21083 HARBOR LN UNIT A
SAINT ROBERT MO
65584-8400
US

IV. Provider business mailing address

21083 HARBOR LN UNIT A
SAINT ROBERT MO
65584-8400
US

V. Phone/Fax

Practice location:
  • Phone: 231-750-2873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: