Healthcare Provider Details

I. General information

NPI: 1497675862
Provider Name (Legal Business Name): KYLE RENE MEDRANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 MURPHY CANYON RD STE 320
SAN DIEGO CA
92123-4453
US

IV. Provider business mailing address

1003 SUSANA CT
SAN MARCOS CA
92078-4629
US

V. Phone/Fax

Practice location:
  • Phone: 858-300-0460
  • Fax:
Mailing address:
  • Phone: 619-936-1789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: