Provider Demographics
NPI:1063607604
Name:KYLE W. SEELEY, DO APC
Entity type:Organization
Organization Name:KYLE W. SEELEY, DO APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SEELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-460-6103
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:#1-210
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-460-6103
Mailing Address - Fax:619-460-6682
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:#1-210
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-460-6103
Practice Address - Fax:619-460-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16785Medicare PIN