Provider Demographics
NPI:1548585979
Name:PETTRY, KYLER RAY
Entity Type:Individual
Prefix:MR
First Name:KYLER
Middle Name:RAY
Last Name:PETTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800C SW 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-4120
Mailing Address - Country:US
Mailing Address - Phone:352-278-3625
Mailing Address - Fax:
Practice Address - Street 1:3800C SW 17TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4120
Practice Address - Country:US
Practice Address - Phone:352-278-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58698172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist