Provider Demographics
NPI:1013751916
Name:GREENE, KYLE (RDN)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 S D ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3205
Mailing Address - Country:US
Mailing Address - Phone:909-388-5655
Mailing Address - Fax:
Practice Address - Street 1:16453 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1752
Practice Address - Country:US
Practice Address - Phone:800-722-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86243005133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered