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General NPI Number Information
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NPI Number | 1962728295
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Entity Type | Organization
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Legal Business Name | KYLE M GILLESPIE O D LTD
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Dates
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Enumeration Date | 04/12/2010
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 701 2ND AVE SE
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City | QUINCY
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State | WA
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Zip | 98848-1531
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Country | US
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Telephone | 509-787-1581
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Fax | 509-787-9176
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Provider Business Mailing Address
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Address Line | 326 W 4100 N
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City | PROVO
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State | UT
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Zip | 84604-6212
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Country | US
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Telephone | 509-797-3641
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Fax | 509-787-9176
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Authorized Official
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Title or Position | PRESIDENT
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Name | KYLE M GILLESPIE
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Credential | OD
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Telephone | 509-797-3641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD60178254
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License Number State | WA
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