Provider Demographics
NPI:1811056310
Name:KYLE CLINIC
Entity type:Organization
Organization Name:KYLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-280-8657
Mailing Address - Street 1:1110 A1A N STE 101
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4071
Mailing Address - Country:US
Mailing Address - Phone:904-280-8657
Mailing Address - Fax:904-280-8659
Practice Address - Street 1:1110 A1A N STE 101
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4071
Practice Address - Country:US
Practice Address - Phone:904-280-8657
Practice Address - Fax:904-280-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA72122Medicare UPIN
FL068272Medicare ID - Type Unspecified