Individual
KYLE FOG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
620 N PONTIAC TRL, WALLED LAKE, MI 48390-3448
(248) 669-2776
Mailing address
620 N PONTIAC TRL, WALLED LAKE, MI 48390-3448
(248) 669-2776
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
5302041191
MI
Other
Enumeration date
05/23/2016
Last updated
05/23/2016
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