Individual
KYLE PHILLIP DIETRICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA STUDENT
Contact information
Practice address
921 S 8TH AVE STOP 8253, POCATELLO, ID 83209-0002
(208) 282-4726
Mailing address
921 S 8TH AVE STOP 8253, POCATELLO, ID 83209-0002
(208) 282-4726
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
LMT-LMT-LIC-15881
MT
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
04/03/2019
Last updated
05/05/2024
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