Provider Demographics
NPI:1659678167
Name:FORTSON, KYLE BRUCE
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:BRUCE
Last Name:FORTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5872
Mailing Address - Country:US
Mailing Address - Phone:626-579-8506
Mailing Address - Fax:626-433-1029
Practice Address - Street 1:12310 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5872
Practice Address - Country:US
Practice Address - Phone:626-579-8506
Practice Address - Fax:626-433-1029
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator