Healthcare Provider Details

I. General information

NPI: 1366026601
Provider Name (Legal Business Name): KYLE STEWART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4408 E PONY EXPRESS PKWY STE A
EAGLE MOUNTAIN UT
84005-5564
US

IV. Provider business mailing address

4408 E PONY EXPRESS PKWY STE A
EAGLE MOUNTAIN UT
84005-5564
US

V. Phone/Fax

Practice location:
  • Phone: 801-702-8180
  • Fax:
Mailing address:
  • Phone: 801-702-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14287722-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: