Provider Demographics
NPI:1518990969
Name:PRUSSO, KYLE L (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:L
Last Name:PRUSSO
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 1:1 VALHALLA LN
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4371
Mailing Address - Country:US
Mailing Address - Phone:925-766-8275
Mailing Address - Fax:925-449-1302
Practice Address - Street 1:530 HAYWOOD RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2711
Practice Address - Country:US
Practice Address - Phone:925-766-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29328111N00000X
CA15362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0293280Medicare PIN