Provider Demographics
NPI:1588860779
Name:LEAVITT, KYLE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:LEE
Last Name:LEAVITT
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 1:8761 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1698
Mailing Address - Country:US
Mailing Address - Phone:801-733-9393
Mailing Address - Fax:
Practice Address - Street 1:8761 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-1698
Practice Address - Country:US
Practice Address - Phone:801-733-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3082863-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT56273Medicare ID - Type Unspecified