Healthcare Provider Details

I. General information

NPI: 1376322099
Provider Name (Legal Business Name): MR. KYLER CONN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N MAIN ST
CEDARVILLE OH
45314-8564
US

IV. Provider business mailing address

14384 BLESSING CHAPEL RD
JEFFERSONVILLE OH
43128-9625
US

V. Phone/Fax

Practice location:
  • Phone: 740-313-2696
  • Fax:
Mailing address:
  • Phone: 740-313-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: