Provider Demographics
NPI:1790348357
Name:NICASTRO, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:NICASTRO
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 1:13 EDDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2639
Mailing Address - Country:US
Mailing Address - Phone:856-816-5285
Mailing Address - Fax:
Practice Address - Street 1:235 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-4000
Practice Address - Country:US
Practice Address - Phone:609-820-4318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0052972255A2300X
NJ25MT001948002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer