Provider Demographics
NPI:1750929220
Name:KINETIC HEALTH AND PERFORMANCE
Entity type:Organization
Organization Name:KINETIC HEALTH AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPORTS THERAPIST / FUNCTIONAL REHAB
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MSR
Authorized Official - Phone:618-619-8200
Mailing Address - Street 1:2706 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5900 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2700
Practice Address - Country:US
Practice Address - Phone:618-619-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center