Provider Demographics
NPI:1528070539
Name:JOHNSON, KYLE MICHAEL (ATC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6660 KODIAK RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:IL
Mailing Address - Zip Code:62561-6017
Mailing Address - Country:US
Mailing Address - Phone:217-566-2155
Mailing Address - Fax:
Practice Address - Street 1:320 E CARPENTER ST
Practice Address - Street 2:1-B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5185
Practice Address - Country:US
Practice Address - Phone:217-744-8000
Practice Address - Fax:217-744-8004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer