Healthcare Provider Details

I. General information

NPI: 1730840141
Provider Name (Legal Business Name): KYLE DIEDRICH KUTSUP ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CONESTOGA TRL
SPARTA NJ
07871-2507
US

IV. Provider business mailing address

35 CONESTOGA TRL
SPARTA NJ
07871-2507
US

V. Phone/Fax

Practice location:
  • Phone: 973-460-7708
  • Fax:
Mailing address:
  • Phone: 973-460-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00184400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: