Provider Demographics
NPI:1295016814
Name:BLAIR, KYLE JORDAN (DPT)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JORDAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FITNESS LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-7080
Mailing Address - Country:US
Mailing Address - Phone:304-258-1300
Mailing Address - Fax:304-258-1400
Practice Address - Street 1:23 FITNESS LN
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-7080
Practice Address - Country:US
Practice Address - Phone:304-258-1300
Practice Address - Fax:304-258-1400
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist