Provider Demographics
NPI:1356446926
Name:KELLY CHIROPRACTIC CENTER, PA
Entity Type:Organization
Organization Name:KELLY CHIROPRACTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-214-6887
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-1483
Mailing Address - Country:US
Mailing Address - Phone:701-838-5000
Mailing Address - Fax:701-852-1184
Practice Address - Street 1:1825 16TH ST SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6428
Practice Address - Country:US
Practice Address - Phone:701-838-5000
Practice Address - Fax:701-852-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890841KMedicaid
NC2453933Medicare ID - Type Unspecified