Provider Demographics
NPI:1073158440
Name:OLANDT, KYLE JORDAN (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JORDAN
Last Name:OLANDT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32261 CAMINO CAPISTRANO
Mailing Address - Street 2:STE D101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3747
Mailing Address - Country:US
Mailing Address - Phone:818-421-4745
Mailing Address - Fax:
Practice Address - Street 1:32261 CAMINO CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3746
Practice Address - Country:US
Practice Address - Phone:818-421-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist