Provider Demographics
NPI:1295128395
Name:THOMAS, KYLE (LAC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 LAKES DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523-7888
Mailing Address - Country:US
Mailing Address - Phone:907-209-9875
Mailing Address - Fax:
Practice Address - Street 1:777 GLOUCESTER ST STE 305
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-0002
Practice Address - Country:US
Practice Address - Phone:912-574-7053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK174171100000X
GA530171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist