Provider Demographics
NPI:1679089981
Name:FREDERICK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FREDERICK
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 1:2 REGENCY PLZ STE 3
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-3149
Mailing Address - Country:US
Mailing Address - Phone:401-484-1706
Mailing Address - Fax:401-437-6959
Practice Address - Street 1:2 REGENCY PLZ STE 3
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3149
Practice Address - Country:US
Practice Address - Phone:401-484-1706
Practice Address - Fax:401-437-6959
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG