Provider Demographics
NPI:1780648279
Name:RADKE, KHYLE EDMUND (ATC)
Entity Type:Individual
Prefix:MR
First Name:KHYLE
Middle Name:EDMUND
Last Name:RADKE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 PINE ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:MN
Mailing Address - Zip Code:56175-1700
Mailing Address - Country:US
Mailing Address - Phone:507-629-4382
Mailing Address - Fax:
Practice Address - Street 1:251 5TH ST E
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1536
Practice Address - Country:US
Practice Address - Phone:507-212-4168
Practice Address - Fax:507-212-4166
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer