MEDICARE: KYLE ALCOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1558847764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE ALCOCK

Provider Business Mailing Address
First Line	:	9434 LIMA RD STE C
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8934
Country	:	US
Telephone Number	:	260-492-9334
Fax Number	:

Provider Business Practice Location Address
First Line	:	9434 LIMA RD STE C
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8934
Country	:	US
Telephone Number	:	260-492-9334
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	06/11/2019

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