Provider Demographics
NPI:1518968635
Name:MC COY, KELLY K (DC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:K
Last Name:MC COY
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:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56048-0148
Mailing Address - Country:US
Mailing Address - Phone:507-234-5134
Mailing Address - Fax:507-234-5134
Practice Address - Street 1:133 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56048-9538
Practice Address - Country:US
Practice Address - Phone:507-234-5134
Practice Address - Fax:507-234-5134
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2529111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN582228900Medicaid
T66216Medicare UPIN
MN582228900Medicaid