Basic Information
| Provider Information | |||||||||
| NPI: | 1518416007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | KYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WELLMORE DR. | ||||||||
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| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038357000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 34TH STREET | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192321058 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2016 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3667 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1518416007 | 05 | SC | MEDICAID |