Provider Demographics
NPI:1831702950
Name:GOSSELIN, KYLE LEONARD (IDC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:LEONARD
Last Name:GOSSELIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 DODSON ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4432
Mailing Address - Country:US
Mailing Address - Phone:805-342-9300
Mailing Address - Fax:805-915-1794
Practice Address - Street 1:2600 DODSON ST STE 3
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4432
Practice Address - Country:US
Practice Address - Phone:805-342-9300
Practice Address - Fax:805-915-1794
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman