Provider Demographics
NPI:1134266331
Name:TETZ, KYLE RYAN (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:RYAN
Last Name:TETZ
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 1:410 S MELROSE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6623
Mailing Address - Country:US
Mailing Address - Phone:760-630-8060
Mailing Address - Fax:760-630-8060
Practice Address - Street 1:410 S MELROSE DR STE 200
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081
Practice Address - Country:US
Practice Address - Phone:760-630-8060
Practice Address - Fax:760-630-8060
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAZ072ZMedicare UPIN