Provider Demographics
NPI:1376579144
Name:NORDRUM, KRISTOPHER SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:SHANE
Last Name:NORDRUM
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 1:120 SUNSET RIDGE AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:GAYS MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:54631-8331
Mailing Address - Country:US
Mailing Address - Phone:630-542-1659
Mailing Address - Fax:
Practice Address - Street 1:120 SUNSET RIDGE AVE STE 109
Practice Address - Street 2:
Practice Address - City:GAYS MILLS
Practice Address - State:WI
Practice Address - Zip Code:54631-8331
Practice Address - Country:US
Practice Address - Phone:630-542-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011034111N00000X
WI4223-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor