Provider Demographics
NPI:1215358197
Name:WALSH, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 W DIVERSEY PKWY
Mailing Address - Street 2:212
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1501
Mailing Address - Country:US
Mailing Address - Phone:773-888-2566
Mailing Address - Fax:
Practice Address - Street 1:639 W DIVERSEY PKWY
Practice Address - Street 2:212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1501
Practice Address - Country:US
Practice Address - Phone:773-888-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001037171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist