Provider Demographics
NPI:1568208437
Name:MELENDEZ, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MELENDEZ
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 1:7320 WOODLAKE AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1470
Mailing Address - Country:US
Mailing Address - Phone:949-680-9800
Mailing Address - Fax:
Practice Address - Street 1:309 E 2ND ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1854
Practice Address - Country:US
Practice Address - Phone:190-962-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant