Provider Demographics
NPI:1104026913
Name:KEOUGH CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:KEOUGH CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:KEOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-783-4950
Mailing Address - Street 1:12139 MOUNT VERNON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5519
Mailing Address - Country:US
Mailing Address - Phone:909-783-4950
Mailing Address - Fax:909-783-1008
Practice Address - Street 1:12139 MOUNT VERNON AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5519
Practice Address - Country:US
Practice Address - Phone:909-783-4950
Practice Address - Fax:909-783-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ30315ZMedicare PIN