Provider Demographics
NPI:1972653145
Name:GANTZ, KYLE EDWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EDWIN
Last Name:GANTZ
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 1:645 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9709
Practice Address - Country:US
Practice Address - Phone:937-592-6321
Practice Address - Fax:937-592-7644
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552821Medicaid
OH2552821Medicaid
OHGA4147371Medicare ID - Type Unspecified
OHV02456Medicare UPIN