Provider Demographics
NPI:1386664761
Name:VAN SANT, KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:VAN SANT
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 1:101 WATER WAY
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-2316
Mailing Address - Country:US
Mailing Address - Phone:410-758-3800
Mailing Address - Fax:410-758-2022
Practice Address - Street 1:101 WATER WAY
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-2316
Practice Address - Country:US
Practice Address - Phone:410-758-3800
Practice Address - Fax:410-758-2022
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS02138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDO78N954FMedicare ID - Type Unspecified
MDU94933Medicare UPIN