Provider Demographics
NPI:1659572048
Name:KOLLBAUM CHIROPRACTIC LIMITED
Entity Type:Organization
Organization Name:KOLLBAUM CHIROPRACTIC LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:KOLLBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-273-3175
Mailing Address - Street 1:430 N MAPLE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-9029
Mailing Address - Country:US
Mailing Address - Phone:715-273-3175
Mailing Address - Fax:715-273-3427
Practice Address - Street 1:430 N MAPLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-9029
Practice Address - Country:US
Practice Address - Phone:715-273-3175
Practice Address - Fax:715-273-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4077012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000035697OtherMEDICARE
WI38958400Medicaid
MN49D86KOOtherBCBS MN
DF7950OtherMEDICARE RAILROAD
DF7950OtherMEDICARE RAILROAD
DF7950OtherMEDICARE RAILROAD