Provider Demographics
NPI:1720416035
Name:ROOTSAERT, KYLE BERTRAND
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:BERTRAND
Last Name:ROOTSAERT
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 1:16834 TRAIN STATION CT
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8638
Mailing Address - Country:US
Mailing Address - Phone:801-885-5959
Mailing Address - Fax:
Practice Address - Street 1:1906 VISTA DEL LAGO DR STE G
Practice Address - Street 2:
Practice Address - City:VALLEY SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95252-9700
Practice Address - Country:US
Practice Address - Phone:209-920-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist