Provider Demographics
NPI:1215554449
Name:GAINES, KYLE WILFRED (PT, ATC/L)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:WILFRED
Last Name:GAINES
Suffix:
Gender:M
Credentials:PT, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 CAPITAL CIR NE STE 106
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1115
Mailing Address - Country:US
Mailing Address - Phone:850-725-5008
Mailing Address - Fax:
Practice Address - Street 1:2743 CAPITAL CIR NE STE 106
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-1115
Practice Address - Country:US
Practice Address - Phone:850-725-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18522255A2300X
FL21204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer