Provider Demographics
NPI:1558131631
Name:TACKEBERRY, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TACKEBERRY
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 1:519 GRANBY XING
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-4351
Mailing Address - Country:US
Mailing Address - Phone:704-698-7675
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:803-216-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC264953163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse