Provider Demographics
NPI:1508380072
Name:OTTENBACHER, KYLE JONATHAN (ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JONATHAN
Last Name:OTTENBACHER
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 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9414 RIDGETOP BLVD NW STE 106
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8526
Practice Address - Country:US
Practice Address - Phone:360-286-2647
Practice Address - Fax:360-286-2652
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer