Provider Demographics
NPI:1689063265
Name:KOMP, ETHAN KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:KYLE
Last Name:KOMP
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 1:8139 RENNER RD APT 3
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-8009
Mailing Address - Country:US
Mailing Address - Phone:785-760-5503
Mailing Address - Fax:
Practice Address - Street 1:2310 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2602
Practice Address - Country:US
Practice Address - Phone:816-404-6489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05675111N00000X
MO2016010041111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor