Basic Information
| Provider Information | |||||||||
| NPI: | 1417317348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLAN | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 CATAWBA CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292015252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786974943 | ||||||||
| FaxNumber: | 8035096390 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346812 | ||||||||
| FaxNumber: | 8034347306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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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 | 2255A2300X | 1628 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 2000015215 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2000015215 | 01 | MA | BOC LICENSURE | OTHER | 1628 | 01 | SC | DHEC STATE CERTIFICATION | OTHER |