Provider Demographics
NPI:1164597530
Name:CARMACK, KELLY BARTON
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BARTON
Last Name:CARMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928
Mailing Address - Country:US
Mailing Address - Phone:530-354-0484
Mailing Address - Fax:
Practice Address - Street 1:107 PARMAC ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926
Practice Address - Country:US
Practice Address - Phone:530-891-2964
Practice Address - Fax:530-895-6683
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator