Provider Demographics
NPI:1538709290
Name:KEITH, KYLE RYAN
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:RYAN
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MURPHY DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-6913
Mailing Address - Country:US
Mailing Address - Phone:479-544-8901
Mailing Address - Fax:
Practice Address - Street 1:25 MURPHY DR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715-6913
Practice Address - Country:US
Practice Address - Phone:479-544-8901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist