Provider Demographics
NPI:1225176126
Name:KELLY, LARRY NEIL (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:NEIL
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 1:141 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3708
Mailing Address - Country:US
Mailing Address - Phone:360-249-2745
Mailing Address - Fax:360-249-2745
Practice Address - Street 1:141 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-3708
Practice Address - Country:US
Practice Address - Phone:360-249-2745
Practice Address - Fax:360-249-2745
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32162Medicare UPIN
WAAB32161Medicare ID - Type UnspecifiedMEDICARE GROUP