Provider Demographics
NPI:1083157051
Name:MCKEIGHAN, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MCKEIGHAN
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 1:639 W COULTER AVE
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2527
Mailing Address - Country:US
Mailing Address - Phone:307-754-9262
Mailing Address - Fax:307-754-9283
Practice Address - Street 1:711 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2442
Practice Address - Country:US
Practice Address - Phone:518-690-2882
Practice Address - Fax:518-690-2884
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400351023OtherMEDICARE
NY04661125Medicaid