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General NPI Number Information
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NPI Number | 1679910855
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Entity Type | Individual
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Provider Name | KYLE RYAN FORNOFF DPT
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Gender | Male
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Dates
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Enumeration Date | 05/29/2013
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Last Update Date | 04/21/2017
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Provider Practice Location Address
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Address Line | 523 10TH ST
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City | GOTHENBURG
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State | NE
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Zip | 69138-1925
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Country | US
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Telephone | 308-537-3600
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Fax | 308-537-3601
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Provider Business Mailing Address
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Address Line | 325 S 1ST AVE P.O. BOX 435
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City | BROKEN BOW
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State | NE
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Zip | 68822-2213
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Country | US
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Telephone | 308-872-5111
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Fax | 308-872-5115
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 3212
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License Number State | NE
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