Provider Demographics
NPI:1073701645
Name:ELLIOTT, KYLE EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EUGENE
Last Name:ELLIOTT
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 1:3880 S BASCOM AVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2674
Mailing Address - Country:US
Mailing Address - Phone:408-559-1100
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2674
Practice Address - Country:US
Practice Address - Phone:408-559-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 27052111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor