Provider Demographics
NPI:1417270364
Name:BOYDSTON, KALEB (MS, ATC)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:BOYDSTON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SILVER CREEK CT
Mailing Address - Street 2:APT 2A
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4900
Practice Address - Country:US
Practice Address - Phone:816-383-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-07
Last Update Date:2011-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, DEVELOPMENTAL, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS