Provider Demographics
NPI:1518919307
Name:ERVIN, KYLE VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:VINCENT
Last Name:ERVIN
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 1:1821 22ND ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1449
Mailing Address - Country:US
Mailing Address - Phone:515-222-4442
Mailing Address - Fax:
Practice Address - Street 1:1821 22ND ST
Practice Address - Street 2:SUITE 113
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1449
Practice Address - Country:US
Practice Address - Phone:515-222-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAVO6777Medicare UPIN