Provider Demographics
NPI:1912760463
Name:FORMAN, KYLE ALLAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:ALLAN
Last Name:FORMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 STILL WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-9276
Mailing Address - Country:US
Mailing Address - Phone:407-462-7610
Mailing Address - Fax:
Practice Address - Street 1:2200 CROW LN
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1663
Practice Address - Country:US
Practice Address - Phone:843-848-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist