Provider Demographics
NPI:1083895221
Name:KELLEY BOULEVARD CHIROPRACTIC
Entity Type:Organization
Organization Name:KELLEY BOULEVARD CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:GRUDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-699-2228
Mailing Address - Street 1:72 TAUNTON ST STE G01
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02762-2132
Mailing Address - Country:US
Mailing Address - Phone:508-699-2228
Mailing Address - Fax:508-699-2228
Practice Address - Street 1:72 TAUNTON ST STE G01
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:MA
Practice Address - Zip Code:02762-2132
Practice Address - Country:US
Practice Address - Phone:508-699-2228
Practice Address - Fax:508-699-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT43401Medicare UPIN