Provider Demographics
NPI:1164946208
Name:GRISIUS, KYLE EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EVAN
Last Name:GRISIUS
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 1:1642 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3018
Mailing Address - Country:US
Mailing Address - Phone:312-792-1900
Mailing Address - Fax:
Practice Address - Street 1:1642 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3018
Practice Address - Country:US
Practice Address - Phone:312-792-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33971111N00000X
IL038013197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor