Provider Demographics
NPI:1083874846
Name:KELLY, KEVIN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:233 E THOUSAND OAKS BLVD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-496-6104
Mailing Address - Fax:805-496-6144
Practice Address - Street 1:15901 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 420
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2655
Practice Address - Country:US
Practice Address - Phone:805-496-6104
Practice Address - Fax:805-496-6144
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC17725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor