Provider Demographics
NPI:1164121653
Name:PEREBOROW, KYLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PEREBOROW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2044
Mailing Address - Country:US
Mailing Address - Phone:310-428-3662
Mailing Address - Fax:
Practice Address - Street 1:1154 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-7169
Practice Address - Country:US
Practice Address - Phone:619-486-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3036942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic