Healthcare Provider Details

I. General information

NPI: 1225677644
Provider Name (Legal Business Name): KYLE WILLIAM RAY VAIL BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 S WESTERN AVE
OKLAHOMA CITY OK
73109-4520
US

IV. Provider business mailing address

305 S ENGLISH DR
MOORE OK
73160-7107
US

V. Phone/Fax

Practice location:
  • Phone: 405-623-9773
  • Fax: 405-685-1944
Mailing address:
  • Phone: 405-496-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: