Provider Demographics
NPI:1134120058
Name:KELLY, CORVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:CORVIN
Middle Name:
Last Name:KELLY
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 1:74976 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-7117
Mailing Address - Country:US
Mailing Address - Phone:760-568-5455
Mailing Address - Fax:760-568-5444
Practice Address - Street 1:74976 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-7117
Practice Address - Country:US
Practice Address - Phone:760-568-5455
Practice Address - Fax:760-568-5444
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0260740Medicare PIN
CAU89276Medicare UPIN