Provider Demographics
NPI:1093027435
Name:GILBERT, KELLY MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MATTHEW
Last Name:GILBERT
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 1:6328 SAGE BRUSH RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4965
Mailing Address - Country:US
Mailing Address - Phone:912-550-6147
Mailing Address - Fax:
Practice Address - Street 1:1705 BOULEVARD SQ STE C
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8032
Practice Address - Country:US
Practice Address - Phone:912-283-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor