Provider Demographics
NPI:1659695096
Name:CROSS, KYLE K
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:K
Last Name:CROSS
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:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0054
Mailing Address - Country:US
Mailing Address - Phone:423-288-5399
Mailing Address - Fax:423-288-4694
Practice Address - Street 1:1409 LINVILLE ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2207
Practice Address - Country:US
Practice Address - Phone:423-288-5399
Practice Address - Fax:423-288-4694
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00029481171W00000X, 171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications