Provider Demographics
NPI:1740371657
Name:KREBAUM, KYLE J (DC)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:KREBAUM
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 1:1027 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-4219
Mailing Address - Country:US
Mailing Address - Phone:620-603-6688
Mailing Address - Fax:
Practice Address - Street 1:1027 JACKSON ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4219
Practice Address - Country:US
Practice Address - Phone:620-603-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS062259Medicaid
KSV07999Medicare UPIN
KS062259Medicare ID - Type Unspecified