Provider Demographics
NPI:1710486832
Name:KELLY, SHANE PITMAN (DC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:PITMAN
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 1:10803 VISTA SORRENTO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2792
Mailing Address - Country:US
Mailing Address - Phone:619-777-3019
Mailing Address - Fax:
Practice Address - Street 1:10803 VISTA SORRENTO PKWY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2792
Practice Address - Country:US
Practice Address - Phone:197-773-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-04
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC34126111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC34126OtherCHIROPRACTIC LICENSE