Provider Demographics
NPI:1407815459
Name:KELLEY, GAYLORD LEE JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GAYLORD
Middle Name:LEE
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:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-0394
Mailing Address - Country:US
Mailing Address - Phone:843-248-5814
Mailing Address - Fax:843-248-0116
Practice Address - Street 1:1238 PINE ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-248-5814
Practice Address - Fax:843-248-0116
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1407111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU646630281Medicare ID - Type Unspecified
SC582275795Medicare UPIN