MEDICARE: KOLLBAUM CHIROPRACTIC LIMITED

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	4077012	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000035697	OTHER		MEDICARE
4	DF7950	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	49D86KO	OTHER	MN	BCBS MN

General Provider Information

NPI Number	:	1659572048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOLLBAUM CHIROPRACTIC LIMITED

Provider Business Mailing Address
First Line	:	430 N MAPLE ST
Second Line	:	SUITE 200
City	:	ELLSWORTH
State	:	WI
Zip	:	54011-9029
Country	:	US
Telephone Number	:	715-273-3175
Fax Number	:	715-273-3427

Provider Business Practice Location Address
First Line	:	430 N MAPLE ST
Second Line	:	SUITE 200
City	:	ELLSWORTH
State	:	WI
Zip	:	54011-9029
Country	:	US
Telephone Number	:	715-273-3175
Fax Number	:	715-273-3427

Authorized Official
Title or Position	:	CEO
Name	:	DR. KYLE TIMOTHY KOLLBAUM
Credential	:	DC
Telephone Number	:	715-273-3175

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	01/22/2013

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Directions to “KOLLBAUM CHIROPRACTIC LIMITED ” Practice Location

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