Healthcare Provider Details

I. General information

NPI: 1871572321
Provider Name (Legal Business Name): GREGORY J NYSTROM DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 KEPLER DR
GREEN BAY WI
54311-8306
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5555
  • Fax:
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-468-9785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3062
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: