Provider Demographics
NPI:1700580701
Name:FRERKING, KYLE JORDAN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JORDAN
Last Name:FRERKING
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-1948
Mailing Address - Country:US
Mailing Address - Phone:816-783-7179
Mailing Address - Fax:
Practice Address - Street 1:800 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-6001
Practice Address - Country:US
Practice Address - Phone:816-783-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer