Provider Demographics
NPI:1689116824
Name:CASEY, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:CASEY
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 1:18025 FORT ST.
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193
Mailing Address - Country:US
Mailing Address - Phone:734-225-7171
Mailing Address - Fax:
Practice Address - Street 1:18025 FORT ST
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7432
Practice Address - Country:US
Practice Address - Phone:734-225-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5306004711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5306004711OtherSTATE OF MICHIGAN- DME LICENSE