Basic Information
| Provider Information | |||||||||
| NPI: | 1427481977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KYLE HOMERTGEN, DO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1893 | ||||||||
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| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391893 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 442 NW 4TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973306491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2013 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOMERTGEN | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5416024373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | DO151041 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.