Healthcare Provider Details

I. General information

NPI: 1760021018
Provider Name (Legal Business Name): KYLER LUKE TEMPLETON LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2020
Last Update Date: 01/04/2020
Certification Date: 01/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 47TH ST
LUBBOCK TX
79413-4112
US

IV. Provider business mailing address

7711 AVENUE J
LUBBOCK TX
79423-4527
US

V. Phone/Fax

Practice location:
  • Phone: 806-219-1954
  • Fax:
Mailing address:
  • Phone: 325-370-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT5910
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: