Provider Demographics
NPI:1558984310
Name:VINCENT, KYLE MATTHEW (LAT, ATC, EMR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
Last Name:VINCENT
Suffix:
Gender:M
Credentials:LAT, ATC, EMR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CHURCH POINT
Mailing Address - State:LA
Mailing Address - Zip Code:70525-2918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S BOBCAT DR
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-4266
Practice Address - Country:US
Practice Address - Phone:337-457-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH2003632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer