Provider Demographics
NPI:1245508498
Name:BRISTOW, KYLE S (LMP)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:S
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1033 REGENTS BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6045
Mailing Address - Country:US
Mailing Address - Phone:253-564-1288
Mailing Address - Fax:253-564-1752
Practice Address - Street 1:1033 REGENTS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6045
Practice Address - Country:US
Practice Address - Phone:253-564-1288
Practice Address - Fax:253-564-1752
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60141206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist