Provider Demographics
NPI:1992701056
Name:KOLLBAUM, KYLE TIMOTHY (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:TIMOTHY
Last Name:KOLLBAUM
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:W4083 490TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-5823
Mailing Address - Country:US
Mailing Address - Phone:715-273-5901
Mailing Address - Fax:715-273-3427
Practice Address - Street 1:430 N MAPLE ST
Practice Address - Street 2:STE 200
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-9029
Practice Address - Country:US
Practice Address - Phone:715-273-3175
Practice Address - Fax:715-273-3427
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4077-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38958400Medicaid
WI412011981012OtherBLUE CROSS BLUE SHIELD
MN49D87KOOtherBLUE CROSS BLUE SHIELD
WI412011981012OtherBLUE CROSS BLUE SHIELD