Individual
KYLE LEE BASTIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CPO
Contact information
Practice address
1432 MADISON 212, FREDERICKTOWN, MO 63645-8208
(520) 904-1079
Mailing address
1432 MADISON 212, FREDERICKTOWN, MO 63645-8208
(520) 904-1079
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Enumeration date
01/01/2008
Last updated
01/01/2008
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