Provider Demographics
NPI:1922663970
Name:PETRINA, KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:PETRINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 BRIGHTON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-3153
Mailing Address - Country:US
Mailing Address - Phone:770-689-6399
Mailing Address - Fax:
Practice Address - Street 1:2095 HIGHWAY 211 NW STE 3A
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3403
Practice Address - Country:US
Practice Address - Phone:678-710-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010201111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor