Healthcare Provider Details

I. General information

NPI: 1629488986
Provider Name (Legal Business Name): KYLE GIBBONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ALFRED DR
ORLANDO FL
32810-5506
US

IV. Provider business mailing address

PO BOX 570439
ORLANDO FL
32857-0439
US

V. Phone/Fax

Practice location:
  • Phone: 855-403-5312
  • Fax:
Mailing address:
  • Phone: 855-403-5312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: