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General NPI Number Information
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NPI Number | 1992701056
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Entity Type | Individual
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Provider Name | KYLE TIMOTHY KOLLBAUM D.C.
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Gender | Male
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Dates
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Enumeration Date | 06/23/2005
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Last Update Date | 01/22/2013
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Provider Practice Location Address
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Address Line | 430 N MAPLE ST STE 200
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City | ELLSWORTH
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State | WI
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Zip | 54011-9029
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Country | US
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Telephone | 715-273-3175
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Fax | 715-273-3427
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Provider Business Mailing Address
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Address Line | W4083 490TH AVE
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City | ELLSWORTH
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State | WI
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Zip | 54011-5823
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Country | US
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Telephone | 715-273-5901
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Fax | 715-273-3427
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4077-012
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License Number State | WI
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