Provider Demographics
NPI:1366463804
Name:LANGE, KELLY MARIE (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:LANGE
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 1:382 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1502
Mailing Address - Country:US
Mailing Address - Phone:541-301-4200
Mailing Address - Fax:
Practice Address - Street 1:108 E HERSEY ST
Practice Address - Street 2:# 2
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1363
Practice Address - Country:US
Practice Address - Phone:541-482-3492
Practice Address - Fax:541-482-4203
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233002Medicaid
ORU99560Medicare UPIN
OR233002Medicaid