Provider Demographics
NPI:1215300835
Name:BLANTON, KYLE (RD, LDN, LD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BLANTON
Suffix:
Gender:M
Credentials:RD, LDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 A E. PRIEN LAKE RD.
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707A E. PRIEN LAKE RD.
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-478-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1096369133V00000X
LA2638133V00000X
TXDT83099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered