Provider Demographics
NPI:1245752104
Name:SANDERS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SANDERS
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:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:1678-459-3745
Mailing Address - Fax:
Practice Address - Street 1:8199 NAVARRE PKWY STE 12A
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-6941
Practice Address - Country:US
Practice Address - Phone:850-939-1233
Practice Address - Fax:850-939-5097
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist