Provider Demographics
NPI:1598803132
Name:VAN ROON, KELLIE (DC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:VAN ROON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:ARRUDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:391 E CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-1350
Mailing Address - Country:US
Mailing Address - Phone:508-553-8981
Mailing Address - Fax:508-553-0550
Practice Address - Street 1:391 E CENTRAL ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-1350
Practice Address - Country:US
Practice Address - Phone:508-553-8981
Practice Address - Fax:508-553-0550
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2289111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1612921Medicaid
MAY45234Medicare ID - Type Unspecified
MA1612921Medicaid