Provider Demographics
NPI:1689678518
Name:KELLY, STEPHEN (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KELLY
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 1:403 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:15697-1154
Mailing Address - Country:US
Mailing Address - Phone:724-925-9220
Mailing Address - Fax:724-925-3742
Practice Address - Street 1:403 S 3RD ST
Practice Address - Street 2:
Practice Address - City:YOUNGWOOD
Practice Address - State:PA
Practice Address - Zip Code:15697-1154
Practice Address - Country:US
Practice Address - Phone:724-925-9220
Practice Address - Fax:724-925-3742
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008792111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA055129Medicare ID - Type UnspecifiedMEDICARE ID NUMBER