Healthcare Provider Details

I. General information

NPI: 1336814896
Provider Name (Legal Business Name): KYLE EVAN BRINLEE CST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N 10TH AVE
STAYTON OR
97383-1399
US

IV. Provider business mailing address

7630 6TH ST SE
TURNER OR
97392-9532
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-9100
  • Fax:
Mailing address:
  • Phone: 503-586-8979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number131952
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: