Provider Demographics
NPI:1265885909
Name:FREDERICK, KYLE (DC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FREDERICK
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 1:661 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45107-9401
Mailing Address - Country:US
Mailing Address - Phone:513-774-9800
Mailing Address - Fax:888-315-2865
Practice Address - Street 1:11928 MONTGOMERY RD
Practice Address - Street 2:STE 6
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-1789
Practice Address - Country:US
Practice Address - Phone:513-774-9800
Practice Address - Fax:888-315-2865
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4640111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor