Provider Demographics
NPI:1437154804
Name:CORBIN, KYLE G (PT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:G
Last Name:CORBIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5468
Mailing Address - Country:US
Mailing Address - Phone:904-821-6575
Mailing Address - Fax:904-821-6678
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5468
Practice Address - Country:US
Practice Address - Phone:904-821-6575
Practice Address - Fax:904-821-6678
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4507AMedicare ID - Type UnspecifiedMEDICARE