Provider Demographics
NPI:1639352206
Name:ELLISON, KYLE JOHN (DC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JOHN
Last Name:ELLISON
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:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-1077
Mailing Address - Country:US
Mailing Address - Phone:405-387-4011
Mailing Address - Fax:405-387-4041
Practice Address - Street 1:918 N.W. 32ND STREET
Practice Address - Street 2:SUITE NUMBER 918
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065-1077
Practice Address - Country:US
Practice Address - Phone:405-387-4011
Practice Address - Fax:405-387-4041
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor