Provider Demographics
NPI:1396305504
Name:WOOTEN, KYLE (LAC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:LAC
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 164
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0164
Mailing Address - Country:US
Mailing Address - Phone:208-962-1849
Mailing Address - Fax:
Practice Address - Street 1:190 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634
Practice Address - Country:US
Practice Address - Phone:208-962-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006550171100000X
IDACU-361171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist