Healthcare Provider Details

I. General information

NPI: 1922333905
Provider Name (Legal Business Name): KYLE BRASHEAR RD/LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 S TIMBERCREEK AVE
SPRINGFIELD MO
65807-5685
US

IV. Provider business mailing address

3878 S TIMBERCREEK AVE
SPRINGFIELD MO
65807-5685
US

V. Phone/Fax

Practice location:
  • Phone: 573-855-4430
  • Fax:
Mailing address:
  • Phone: 573-855-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2008028024
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: