=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225841554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ANDREW KIELBASA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7822 E RIDGE RD
-----------------------------------------------------
City | HOBART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46342-2468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-962-8128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5974 WINCHESTER PL
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-614-2055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08003499A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------