Provider Demographics
NPI:1205180619
Name:TAKETA, KYLE (DC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TAKETA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 WEST 25TH AVEUNE #4
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403
Mailing Address - Country:US
Mailing Address - Phone:650-349-2222
Mailing Address - Fax:
Practice Address - Street 1:190 W 25TH AVE
Practice Address - Street 2:#4
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2298
Practice Address - Country:US
Practice Address - Phone:650-349-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30996111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor