Provider Demographics
NPI:1750717609
Name:HILDRETH, KYLE (BA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HILDRETH
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 MALORY DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5056
Mailing Address - Country:US
Mailing Address - Phone:208-403-8963
Mailing Address - Fax:
Practice Address - Street 1:543 3RD ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3909
Practice Address - Country:US
Practice Address - Phone:208-522-6925
Practice Address - Fax:208-522-6934
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management