Provider Demographics
NPI:1215020789
Name:GERITANO, KELLY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LYNN
Last Name:GERITANO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12928 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1717
Mailing Address - Country:US
Mailing Address - Phone:708-614-9800
Mailing Address - Fax:708-614-9800
Practice Address - Street 1:7060 CENTENNIAL DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-614-9800
Practice Address - Fax:708-614-9800
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01632592OtherBLUE CROSS BLUE SHIELD
ILU99415Medicare ID - Type Unspecified