Provider Demographics
NPI:1629162896
Name:WOOTEN, KELLIE RAYE (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:RAYE
Last Name:WOOTEN
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 1:102 MOSHEIM ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4908
Mailing Address - Country:US
Mailing Address - Phone:830-386-0340
Mailing Address - Fax:
Practice Address - Street 1:102 MOSHEIM ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4908
Practice Address - Country:US
Practice Address - Phone:830-386-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX606285OtherBCBS PROVIDER NUMBER
TX8B3857Medicare PIN