Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4955 | KY |
NPI | 1003857376 |
---|---|
Provider Name | Dr. Kyle Wellington |
First Address | Louisville, KY 40214-3007 |
Second Address | Louisville, KY 40214-3007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 30/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000580921 | ANTHEM BLUE CROSS BLUE SHIELD (01) | KY |
11470848 | CAQH PROVIDER # (01) | KY |
7100050180 | (05) | KY |