Provider Demographics
NPI:1639114366
Name:KADOLPH, KELLY JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JAY
Last Name:KADOLPH
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:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-0527
Mailing Address - Country:US
Mailing Address - Phone:660-425-3312
Mailing Address - Fax:660-425-3438
Practice Address - Street 1:3307 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2716
Practice Address - Country:US
Practice Address - Phone:660-425-3312
Practice Address - Fax:660-425-3438
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005205111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20768013OtherBLUE CROSS BLUE SHIELD
MO20768013OtherBLUE CROSS BLUE SHIELD
MO0005766Medicare ID - Type Unspecified