Provider Demographics
NPI:1417317348
Name:DOLAN, KYLE (ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DOLAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 CATAWBA CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-5252
Mailing Address - Country:US
Mailing Address - Phone:978-697-4943
Mailing Address - Fax:803-509-6390
Practice Address - Street 1:2 MEDICAL PARK RD STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-434-6812
Practice Address - Fax:803-434-7306
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16282255A2300X
MA20000152152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2000015215OtherBOC LICENSURE
SC1628OtherDHEC STATE CERTIFICATION