Provider Demographics
NPI:1417581455
Name:BISHOP, KYLE ERIC (LAT,ATC,BS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ERIC
Last Name:BISHOP
Suffix:
Gender:M
Credentials:LAT,ATC,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3812 HOPEWELL RD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-5924
Mailing Address - Country:US
Mailing Address - Phone:636-887-6674
Mailing Address - Fax:
Practice Address - Street 1:754 LUETKENHAUS BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3515
Practice Address - Country:US
Practice Address - Phone:636-445-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210273682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty