Healthcare Provider Details

I. General information

NPI: 1215686076
Provider Name (Legal Business Name): KELTON WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 US HIGHWAY 180 W
BRECKENRIDGE TX
76424-8766
US

IV. Provider business mailing address

7501 US HIGHWAY 180 W
BRECKENRIDGE TX
76424-8766
US

V. Phone/Fax

Practice location:
  • Phone: 254-212-9900
  • Fax:
Mailing address:
  • Phone: 254-212-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: