Provider Demographics
NPI:1053669788
Name:MICHAEL T KELLY DC PA
Entity Type:Organization
Organization Name:MICHAEL T KELLY DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-785-8500
Mailing Address - Street 1:1430 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2134
Mailing Address - Country:US
Mailing Address - Phone:772-785-8500
Mailing Address - Fax:
Practice Address - Street 1:1430 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2134
Practice Address - Country:US
Practice Address - Phone:772-785-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007060111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55396AMedicare UPIN