Healthcare Provider Details

I. General information

NPI: 1568051886
Provider Name (Legal Business Name): KYLE REDDEN DALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20725 HIGHWAY 46 W
SPRING BRANCH TX
78070-6270
US

IV. Provider business mailing address

20725 HIGHWAY 46 W
SPRING BRANCH TX
78070-6270
US

V. Phone/Fax

Practice location:
  • Phone: 830-438-4010
  • Fax:
Mailing address:
  • Phone: 830-438-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number759564
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number297540
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: