Provider Demographics
NPI:1629008362
Name:MAI, KELLY T (DC,LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:MAI
Suffix:
Gender:F
Credentials:DC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1925
Mailing Address - Country:US
Mailing Address - Phone:909-590-3122
Mailing Address - Fax:909-590-3801
Practice Address - Street 1:5266 FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1925
Practice Address - Country:US
Practice Address - Phone:909-590-3122
Practice Address - Fax:909-590-3801
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27481111N00000X
CA9251171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC027481Medicare ID - Type UnspecifiedCHIROPRACTIC