Provider Demographics
NPI:1770708430
Name:EVERSON, KYLE JOHN (ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JOHN
Last Name:EVERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39616 137TH ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:SD
Mailing Address - Zip Code:57427-6504
Mailing Address - Country:US
Mailing Address - Phone:605-225-7002
Mailing Address - Fax:
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD01862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer