Healthcare Provider Details

I. General information

NPI: 1396166047
Provider Name (Legal Business Name): DR. KYLE BUTZINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W LAKE ST
MELROSE PARK IL
60160-4039
US

IV. Provider business mailing address

730 TOPEKA DR
LAKE MILLS WI
53551-1724
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number070.020217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: