Provider Demographics
NPI:1306364997
Name:DOMIN, KYLE JAMES
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMES
Last Name:DOMIN
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 1:605 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:IA
Mailing Address - Zip Code:52142-9206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:IA
Practice Address - Zip Code:52142
Practice Address - Country:US
Practice Address - Phone:630-418-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer