Provider Demographics
NPI:1225333164
Name:KYD KYRO
Entity Type:Organization
Organization Name:KYD KYRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-771-2700
Mailing Address - Street 1:390 MALLORY STATION RD
Mailing Address - Street 2:STE 103
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8279
Mailing Address - Country:US
Mailing Address - Phone:605-771-2700
Mailing Address - Fax:605-771-2799
Practice Address - Street 1:390 MALLORY STATION RD
Practice Address - Street 2:STE 103
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8279
Practice Address - Country:US
Practice Address - Phone:605-771-2700
Practice Address - Fax:605-771-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2364261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3672605OtherMEDICARE PTAN
TN4281756OtherBCBS