Provider Demographics
NPI:1962728295
Name:KYLE M GILLESPIE O D LTD
Entity type:Organization
Organization Name:KYLE M GILLESPIE O D LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-797-3641
Mailing Address - Street 1:326 W 4100 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6212
Mailing Address - Country:US
Mailing Address - Phone:509-797-3641
Mailing Address - Fax:509-787-9176
Practice Address - Street 1:701 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848-1531
Practice Address - Country:US
Practice Address - Phone:509-787-1581
Practice Address - Fax:509-787-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60178254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty