Healthcare Provider Details

I. General information

NPI: 1023561685
Provider Name (Legal Business Name): KYLE LILLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 S 4080 RD
TALALA OK
74080-3539
US

IV. Provider business mailing address

6303 S 4080 RD
TALALA OK
74080-3539
US

V. Phone/Fax

Practice location:
  • Phone: 918-231-2598
  • Fax:
Mailing address:
  • Phone: 918-231-2598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: