Provider Demographics
NPI:1699835983
Name:HENRY, KELLY PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:PAUL
Last Name:HENRY
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 1:1234 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4017
Mailing Address - Country:US
Mailing Address - Phone:505-885-5808
Mailing Address - Fax:505-887-1011
Practice Address - Street 1:1234 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4017
Practice Address - Country:US
Practice Address - Phone:505-885-5808
Practice Address - Fax:505-887-1011
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1467111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU71273Medicare UPIN