Provider Demographics
NPI:1154124774
Name:TESKE, KYLA (ABOC, NCLEC, LDO)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:TESKE
Suffix:
Gender:
Credentials:ABOC, NCLEC, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-5945
Mailing Address - Country:US
Mailing Address - Phone:623-583-8920
Mailing Address - Fax:623-583-8979
Practice Address - Street 1:12900 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-5945
Practice Address - Country:US
Practice Address - Phone:623-583-8920
Practice Address - Fax:623-583-8979
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLDO-003235156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician