Provider Demographics
NPI:1629623053
Name:PRUITT, KELLUS RAY
Entity Type:Individual
Prefix:
First Name:KELLUS
Middle Name:RAY
Last Name:PRUITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 VALLEY OAKS CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2864
Mailing Address - Country:US
Mailing Address - Phone:817-691-6954
Mailing Address - Fax:
Practice Address - Street 1:808 VALLEY OAKS CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2864
Practice Address - Country:US
Practice Address - Phone:817-691-6954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13874111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor