Provider Demographics
NPI:1790960482
Name:BASTIE, KYLE LEE (CPO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LEE
Last Name:BASTIE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 MADISON 212
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-8208
Mailing Address - Country:US
Mailing Address - Phone:520-904-1079
Mailing Address - Fax:
Practice Address - Street 1:1432 MADISON 212
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-8208
Practice Address - Country:US
Practice Address - Phone:520-904-1079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor