Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2132 | TN |
NPI | 1003909128 |
---|---|
Provider Name | Mr. Kyle M Longo |
First Address | Clarksville, TN 37040-8416 |
Second Address | Clarksville, TN 37040-8416 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 29/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4218740 | BCBS PROVIDER# (01) | TN |