Provider Demographics
NPI:1508032384
Name:ROBERTS, KYLE G (C PED)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:G
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W314S2556 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9671
Mailing Address - Country:US
Mailing Address - Phone:262-968-3643
Mailing Address - Fax:
Practice Address - Street 1:W314S2556 PENNY LN
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9671
Practice Address - Country:US
Practice Address - Phone:262-968-3643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter