=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225028699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE MATTHEW ROCKERS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2005
-----------------------------------------------------
Last Update Date | 10/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3165 DEMERS AVE - TRUYU AESTHETIC CENTER
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-780-6623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 DEMERS AVE
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-780-1891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 04-37503
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 15835
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------