Provider Demographics
NPI:1184845067
Name:KELLEHER, TODD F (D C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:F
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 2320
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-2320
Mailing Address - Country:US
Mailing Address - Phone:478-986-6444
Mailing Address - Fax:478-986-1254
Practice Address - Street 1:4292 GRAY HIGHWAY
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032
Practice Address - Country:US
Practice Address - Phone:478-986-6444
Practice Address - Fax:478-986-1254
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA924255206AMedicaid
GAU679868Medicare UPIN
GA35ZCDPHMedicare ID - Type Unspecified