Provider Demographics
NPI:1619013398
Name:BAKER, KELLY W (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:BAKER
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 1:852 MANZANITA CT STE 150
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2399
Mailing Address - Country:US
Mailing Address - Phone:530-897-4188
Mailing Address - Fax:530-345-1835
Practice Address - Street 1:852 MANZANITA CT STE 150
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2399
Practice Address - Country:US
Practice Address - Phone:530-897-4188
Practice Address - Fax:530-345-1835
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0216250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0216250Medicare ID - Type Unspecified