Provider Demographics
NPI:1700200821
Name:WINTERS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WINTERS
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 1:481 DANA MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6493
Mailing Address - Country:US
Mailing Address - Phone:314-626-3161
Mailing Address - Fax:
Practice Address - Street 1:481 DANA MEADOWS LN
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-6493
Practice Address - Country:US
Practice Address - Phone:314-626-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014004340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist