Basic Information
| Provider Information | |||||||||
| NPI: | 1568180784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONIO | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6895 RAMFOS CIR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921393216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195781483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 585 SATURN BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921544721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195911190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 51482 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | F2125959 | 01 | CA | DRIVER'S LICENSE | OTHER |