1306490677 NPI number — MR. KYLE LEONARD BERNIER MAATC

Table of content: MR. KYLE LEONARD BERNIER MAATC (NPI 1306490677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306490677 NPI number — MR. KYLE LEONARD BERNIER MAATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNIER
Provider First Name:
KYLE
Provider Middle Name:
LEONARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MAATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306490677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2785 LEXINGTON AVE N APT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-2018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-540-7382
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 BANDANA BLVD W
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-5323
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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