=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053610956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYLE D. ANDRUS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2011
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 W. SUNSET BLVD SUITE 106
-----------------------------------------------------
City | ST. GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84770-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-628-1112
-----------------------------------------------------
Fax | 435-628-5653
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 FLOUROY LUCAS ROAD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-229-1354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KYLE D. ANDRUS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 435-628-1112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------