Individual
DR. KYLE TIMOTHY KOLLBAUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.C.
Contact information
Practice address
430 N MAPLE ST, STE 200, ELLSWORTH, WI 54011-9029
(715) 273-3175
(715) 273-3427
Mailing address
W4083 490TH AVE, ELLSWORTH, WI 54011-5823
(715) 273-5901
(715) 273-3427
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
4077-012
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
38958400
—
WI
01
—
412011981012
BLUE CROSS BLUE SHIELD
WI
01
—
49D87KO
BLUE CROSS BLUE SHIELD
MN
Enumeration date
06/23/2005
Last updated
01/22/2013
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