Provider Demographics
NPI:1053788943
Name:HAZEN, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HAZEN
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 1:305 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:TX
Mailing Address - Zip Code:79325-5615
Mailing Address - Country:US
Mailing Address - Phone:888-873-4221
Mailing Address - Fax:
Practice Address - Street 1:305 5TH ST
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:TX
Practice Address - Zip Code:79325-5615
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2115371225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant