Provider Demographics
NPI:1124403431
Name:KLEINSCHMIDT, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KLEINSCHMIDT
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 1:3119 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5473
Mailing Address - Country:US
Mailing Address - Phone:618-463-9490
Mailing Address - Fax:618-463-9491
Practice Address - Street 1:3119 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5473
Practice Address - Country:US
Practice Address - Phone:618-463-9490
Practice Address - Fax:618-463-9491
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3207237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3207OtherHEARING AID DISPENSER LICENSE