Provider Demographics
NPI:1679910855
Name:FORNOFF, KYLE RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:RYAN
Last Name:FORNOFF
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S 1ST AVE
Mailing Address - Street 2:P.O. BOX 435
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-2213
Mailing Address - Country:US
Mailing Address - Phone:308-872-5111
Mailing Address - Fax:308-872-5115
Practice Address - Street 1:523 10TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1925
Practice Address - Country:US
Practice Address - Phone:308-537-3600
Practice Address - Fax:308-537-3601
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE$$$$$$$$$00Medicaid
NE$$$$$$$$$00Medicaid