Provider Demographics
NPI:1194088476
Name:KYLE D GUIDRY
Entity type:Organization
Organization Name:KYLE D GUIDRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GUIDRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, ATC
Authorized Official - Phone:623-760-6356
Mailing Address - Street 1:16572 W GREENWAY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-2183
Mailing Address - Country:US
Mailing Address - Phone:623-584-3400
Mailing Address - Fax:623-584-5434
Practice Address - Street 1:15949 N CRISTINE LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-1292
Practice Address - Country:US
Practice Address - Phone:623-518-2127
Practice Address - Fax:623-518-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6398225100000X
AZ3243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty