Healthcare Provider Details

I. General information

NPI: 1336757624
Provider Name (Legal Business Name): KYLE BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 W MAIN ST
ROCHESTER NY
14611-2335
US

IV. Provider business mailing address

835 W MAIN ST
ROCHESTER NY
14611-2335
US

V. Phone/Fax

Practice location:
  • Phone: 585-467-2230
  • Fax:
Mailing address:
  • Phone: 585-467-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number108696
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: