Healthcare Provider Details

I. General information

NPI: 1285033449
Provider Name (Legal Business Name): KLINTON KYLE KUYKENDALL M.ED, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7412 KAYLEE WAY
OKLAHOMA CITY OK
73132-4802
US

IV. Provider business mailing address

7412 KAYLEE WAY
OKLAHOMA CITY OK
73132-4802
US

V. Phone/Fax

Practice location:
  • Phone: 817-913-7269
  • Fax:
Mailing address:
  • Phone: 817-913-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4787
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number869
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: