Provider Demographics
NPI:1164571543
Name:HUBBARD, KELLY LEONARD (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEONARD
Last Name:HUBBARD
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:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-1147
Mailing Address - Country:US
Mailing Address - Phone:971-219-1071
Mailing Address - Fax:
Practice Address - Street 1:10224 SW PARK WAY, SUITE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-297-1174
Practice Address - Fax:503-297-2623
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2927111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor