Healthcare Provider Details

I. General information

NPI: 1124793484
Provider Name (Legal Business Name): KYLE MACEY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16615 LARK AVE STE 101
LOS GATOS CA
95032-7645
US

IV. Provider business mailing address

184 MERRITT RD
LOS ALTOS CA
94022-3027
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-1460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number300568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: