Provider Demographics
NPI:1679223432
Name:OLIVER, KYLE ROBERT
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:OLIVER
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 1:6491 GREEN MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-8285
Mailing Address - Country:US
Mailing Address - Phone:360-609-8407
Mailing Address - Fax:
Practice Address - Street 1:6491 GREEN MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-8285
Practice Address - Country:US
Practice Address - Phone:360-609-8407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer