Provider Demographics
NPI:1639237969
Name:KELLY CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:KELLY CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY-KOHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-231-0143
Mailing Address - Street 1:16980 SADDLEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2678
Mailing Address - Country:US
Mailing Address - Phone:612-702-9206
Mailing Address - Fax:
Practice Address - Street 1:8421 WAYZATA BLVD. SUITE 220
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:763-231-0143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
320S0KEOtherBLUE CROSS BLUE SHIELD #
320S0KEOtherBLUE CROSS BLUE SHIELD #