Provider Demographics
NPI:1770844029
Name:HERRENBRUCK, GREGORY KYLE
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KYLE
Last Name:HERRENBRUCK
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 1:6620 BALLENTINE ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-3824
Mailing Address - Country:US
Mailing Address - Phone:913-484-0790
Mailing Address - Fax:
Practice Address - Street 1:6620 BALLENTINE ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-3824
Practice Address - Country:US
Practice Address - Phone:913-484-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant