Provider Demographics
NPI:1124173109
Name:LEWIS, KYLE RANDOLPH
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RANDOLPH
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:RANDOLPH
Other - Last Name:LEWIS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1605 EASTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1009
Mailing Address - Country:US
Mailing Address - Phone:323-226-8826
Mailing Address - Fax:323-226-2992
Practice Address - Street 1:1605 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1009
Practice Address - Country:US
Practice Address - Phone:323-226-8826
Practice Address - Fax:323-226-2992
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner