Healthcare Provider Details

I. General information

NPI: 1760994735
Provider Name (Legal Business Name): KYLE SIMKOVICH ATC, FMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 MORADA PL
ALTADENA CA
91001-3233
US

IV. Provider business mailing address

1603 MORADA PL
ALTADENA CA
91001-3233
US

V. Phone/Fax

Practice location:
  • Phone: 626-319-4409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC36697
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: