Provider Demographics
NPI:1528112521
Name:FOGEL, KYLE AVIV (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:AVIV
Last Name:FOGEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 BLUEWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518
Mailing Address - Country:US
Mailing Address - Phone:770-945-5953
Mailing Address - Fax:
Practice Address - Street 1:2450 ATLANTA HWY
Practice Address - Street 2:STE 1601
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-513-0095
Practice Address - Fax:678-513-0706
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO7309111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52026308002OtherBCBS
V07187Medicare UPIN
GA52026308002OtherBCBS