Provider Demographics
NPI:1437334547
Name:FENNEMORE, KYLE T (DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:T
Last Name:FENNEMORE
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:100 BECKS WOODS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-3835
Practice Address - Country:US
Practice Address - Phone:302-392-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJT0000684225100000X
DEJ1-0002306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE201637Y0XMedicare PIN