Provider Demographics
NPI:1265651756
Name:KYLE B. POTTS, M.D., INC.
Entity type:Organization
Organization Name:KYLE B. POTTS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:B
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-738-0450
Mailing Address - Street 1:805 W ACEQUIA AVE
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6162
Mailing Address - Country:US
Mailing Address - Phone:559-738-0450
Mailing Address - Fax:559-738-0460
Practice Address - Street 1:805 W ACEQUIA AVE
Practice Address - Street 2:SUITE 2-A
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6162
Practice Address - Country:US
Practice Address - Phone:559-738-0450
Practice Address - Fax:559-738-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64819261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265651756Medicaid
CAWG64819AOtherMEDICARE ID
CAH03402Medicare UPIN