Provider Demographics
NPI:1871572321
Name:NYSTROM, GREGORY J (DC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:NYSTROM
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 1:1441 BELLEVUE ST
Mailing Address - Street 2:BELLEVUE CHIROPRACTIC CLINIC
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5605
Mailing Address - Country:US
Mailing Address - Phone:920-465-7772
Mailing Address - Fax:920-468-9785
Practice Address - Street 1:1441 BELLEVUE ST
Practice Address - Street 2:BELLEVUE CHIROPRACTIC CLINIC
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5605
Practice Address - Country:US
Practice Address - Phone:920-465-7772
Practice Address - Fax:920-468-9785
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3889700Medicaid
WI3889700Medicaid