Provider Demographics
NPI:1043567001
Name:LUIS, KYLE MATTHEW (LPT)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MATTHEW
Last Name:LUIS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 EAST MINARETS
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93650
Mailing Address - Country:US
Mailing Address - Phone:559-436-0482
Mailing Address - Fax:
Practice Address - Street 1:40 EAST MINARETS
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:CA
Practice Address - Zip Code:93650
Practice Address - Country:US
Practice Address - Phone:559-436-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36277167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician