Healthcare Provider Details

I. General information

NPI: 1134840887
Provider Name (Legal Business Name): KYLE IKAIKA VILLANUEVA-KISHIDA RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 LAS VEGAS BLVD N # A2
LAS VEGAS NV
89115-0598
US

IV. Provider business mailing address

1060 WIGWAM PKWY
HENDERSON NV
89074-8162
US

V. Phone/Fax

Practice location:
  • Phone: 702-547-6971
  • Fax: 702-547-6948
Mailing address:
  • Phone: 702-547-6971
  • Fax: 702-547-6948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: