Provider Demographics
NPI:1659452183
Name:MEMMOTT, KYLE D (MPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:MEMMOTT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 FALCON RIDGE PKWY
Mailing Address - Street 2:#500
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-8850
Mailing Address - Country:US
Mailing Address - Phone:702-346-3105
Mailing Address - Fax:702-346-3544
Practice Address - Street 1:340 FALCON RIDGE PKWY
Practice Address - Street 2:#500
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8850
Practice Address - Country:US
Practice Address - Phone:702-346-3105
Practice Address - Fax:702-346-3544
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1828225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504542Medicaid
NVBM123ZMedicare PIN