Provider Demographics
NPI:1194592865
Name:KING, KYLE LEWIS
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:LEWIS
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10925 PALMS BLVD APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6137
Mailing Address - Country:US
Mailing Address - Phone:310-936-2291
Mailing Address - Fax:
Practice Address - Street 1:BURROWES RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802
Practice Address - Country:US
Practice Address - Phone:310-936-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer