Provider Demographics
NPI:1356443972
Name:KELLEY, TIMOTHY MICHAEL JR (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:KELLEY
Suffix:JR
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 1:94 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HEUVELTON
Mailing Address - State:NY
Mailing Address - Zip Code:13654
Mailing Address - Country:US
Mailing Address - Phone:315-344-7296
Mailing Address - Fax:315-344-7296
Practice Address - Street 1:94 STATE ST
Practice Address - Street 2:
Practice Address - City:HEUVELTON
Practice Address - State:NY
Practice Address - Zip Code:13654
Practice Address - Country:US
Practice Address - Phone:315-344-7296
Practice Address - Fax:315-344-7296
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3060111N00000X
NYX011547-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor