MEDICARE: DR. KYLE EVAN GRISIUS DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	33971	CA
2	111N00000X	Chiropractor	038013197	IL

General Provider Information

NPI Number	:	1164946208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE EVAN GRISIUS DC

Provider Business Mailing Address
First Line	:	1642 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3018
Country	:	US
Telephone Number	:	312-792-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1642 W BELMONT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3018
Country	:	US
Telephone Number	:	312-792-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2017
Last Update Date	:	02/01/2024

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