Provider Demographics
NPI:1366834780
Name:BANNER, KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:BANNER
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 1:1543 GLADSTONE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3922
Mailing Address - Country:US
Mailing Address - Phone:616-520-3430
Mailing Address - Fax:
Practice Address - Street 1:1543 GLADSTONE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3922
Practice Address - Country:US
Practice Address - Phone:616-520-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-22
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor