Provider Demographics
NPI:1427481977
Name:KYLE HOMERTGEN, DO, LLC
Entity type:Organization
Organization Name:KYLE HOMERTGEN, DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOMERTGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-602-4373
Mailing Address - Street 1:PO BOX 1893
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 NW 4TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6491
Practice Address - Country:US
Practice Address - Phone:541-758-5047
Practice Address - Fax:541-758-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO151041204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty