Provider Demographics
NPI:1518365717
Name:BOW, KYLE (PTA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BOW
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-2216
Mailing Address - Country:US
Mailing Address - Phone:512-429-1575
Mailing Address - Fax:
Practice Address - Street 1:618 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2216
Practice Address - Country:US
Practice Address - Phone:512-429-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-21
Last Update Date:2014-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084702261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy