Provider Demographics
NPI:1801439989
Name:KYLES, KEITH EDWARD
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:KYLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2398
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2398
Mailing Address - Country:US
Mailing Address - Phone:870-701-5089
Mailing Address - Fax:870-277-0896
Practice Address - Street 1:430 HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519-8852
Practice Address - Country:US
Practice Address - Phone:870-701-5089
Practice Address - Fax:870-270-0896
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14547194OtherCAQH
ARPT1604OtherARKANSAS STATE MEDICAL BOARD