Healthcare Provider Details

I. General information

NPI: 1578438313
Provider Name (Legal Business Name): KISTAL ARMENTA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32326 CLINTON KEITH RD STE 201
WILDOMAR CA
92595-7317
US

IV. Provider business mailing address

600 CENTRAL AVE STE F
LAKE ELSINORE CA
92530-2740
US

V. Phone/Fax

Practice location:
  • Phone: 858-264-5858
  • Fax:
Mailing address:
  • Phone: 951-674-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number10303
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: