Provider Demographics
NPI:1407886153
Name:KEOUGH, KELLY PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:PATRICK
Last Name:KEOUGH
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 1:1944 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7306
Mailing Address - Country:US
Mailing Address - Phone:909-793-5700
Mailing Address - Fax:
Practice Address - Street 1:12139 MOUNT VERNON AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5519
Practice Address - Country:US
Practice Address - Phone:909-783-4950
Practice Address - Fax:909-783-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0138151Medicare PIN