Provider Demographics
NPI:1275822074
Name:DOUGLASS, KELLY T (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:DOUGLASS
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 1:3689 WATERMELON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5139
Mailing Address - Country:US
Mailing Address - Phone:205-758-1600
Mailing Address - Fax:205-758-6698
Practice Address - Street 1:3689 WATERMELON RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5139
Practice Address - Country:US
Practice Address - Phone:205-758-1600
Practice Address - Fax:205-758-6698
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2508111N00000X
AL2335111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4296256OtherBCBS