Provider Demographics
NPI:1316553001
Name:KYLES, CLINTON (CMT, PTT)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:KYLES
Suffix:
Gender:M
Credentials:CMT, PTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4547 MURIETTA AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2957
Mailing Address - Country:US
Mailing Address - Phone:912-256-1286
Mailing Address - Fax:
Practice Address - Street 1:4547 MURIETTA AVE APT 13
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2957
Practice Address - Country:US
Practice Address - Phone:912-256-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75650225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist