Provider Demographics
NPI:1003857376
Name:WELLINGTON, KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:WELLINGTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 EVANGELINE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-3007
Mailing Address - Country:US
Mailing Address - Phone:502-368-9914
Mailing Address - Fax:
Practice Address - Street 1:275 EVANGELINE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-3007
Practice Address - Country:US
Practice Address - Phone:502-368-9914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4955111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100050180Medicaid
KY11470848OtherCAQH PROVIDER #
KY000000580921OtherANTHEM BLUE CROSS BLUE SHIELD
KY1973201Medicare Oscar/Certification
KY7100050180Medicaid