Healthcare Provider Details

I. General information

NPI: 1508426503
Provider Name (Legal Business Name): KYLE SHERWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16978 MANCHESTER RD
WILDWOOD MO
63040-1200
US

IV. Provider business mailing address

2626 WESTHILLS PARK DR UNIT 2318
WILDWOOD MO
63011-4764
US

V. Phone/Fax

Practice location:
  • Phone: 636-273-6336
  • Fax:
Mailing address:
  • Phone: 636-368-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2019021897
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: