Healthcare Provider Details

I. General information

NPI: 1689402414
Provider Name (Legal Business Name): KYLE OREILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

604 W WATER ST
ANAHEIM CA
92805-4448
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7890
  • Fax:
Mailing address:
  • Phone: 714-878-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95209748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: