Healthcare Provider Details

I. General information

NPI: 1386833390
Provider Name (Legal Business Name): KYLE J BERRA ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E. SECOND ST
RICHLAND CENTER WI
53581
US

IV. Provider business mailing address

P.O. BOX 338
NORTH FREEDOM WI
53951
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6321
  • Fax:
Mailing address:
  • Phone: 608-522-4693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number573-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: