Basic Information
| Provider Information | |||||||||
| NPI: | 1275991044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUSTODI | ||||||||
| FirstName: | KYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 N PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142161937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27240 HAGGERTY RD | ||||||||
| Address2: | SUITE E15 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P15989 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.