Provider Demographics
NPI:1083073472
Name:LIPSCOMB, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:LIPSCOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7677 YANKEE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7677 YANKEE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3475
Practice Address - Country:US
Practice Address - Phone:937-401-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0048562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer