Healthcare Provider Details

I. General information

NPI: 1083605141
Provider Name (Legal Business Name): DOUGLAS W KYLE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TAMAL PLAZA SUITE 120
CORTE MADERA CA
94925
US

IV. Provider business mailing address

300 TAMAL PLAZA SUITE 120
CORTE MADERA CA
94925
US

V. Phone/Fax

Practice location:
  • Phone: 415-924-1010
  • Fax: 415-924-1016
Mailing address:
  • Phone: 415-924-1010
  • Fax: 415-924-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number18851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: