Provider Demographics
NPI:1437874641
Name:KELLER, KYLE (RD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7155 CITRUS AVE UNIT 115
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-6001
Mailing Address - Country:US
Mailing Address - Phone:909-900-9655
Mailing Address - Fax:
Practice Address - Street 1:2079 ORANGE TREE LN
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2849
Practice Address - Country:US
Practice Address - Phone:909-353-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86303323133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered