Provider Demographics
NPI:1497764658
Name:MCINTIRE, MICUM KYLE (MS, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:MICUM
Middle Name:KYLE
Last Name:MCINTIRE
Suffix:
Gender:M
Credentials:MS, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NH
Mailing Address - Zip Code:03251-0068
Mailing Address - Country:US
Mailing Address - Phone:603-745-8930
Mailing Address - Fax:603-745-9898
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4933
Practice Address - Country:US
Practice Address - Phone:802-264-1052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH09-0203246ZS0410X
NH03632255A2300X
VT104.00001652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist