Provider Demographics
NPI:1669841391
Name:DATZ, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DATZ
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 1:311 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:PA
Mailing Address - Zip Code:18224-2021
Mailing Address - Country:US
Mailing Address - Phone:570-814-0375
Mailing Address - Fax:
Practice Address - Street 1:311 RIDGE ST
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:PA
Practice Address - Zip Code:18224-2021
Practice Address - Country:US
Practice Address - Phone:570-814-0375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist