Provider Demographics
NPI:1760056006
Name:KELLY, BRIAN THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
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 1:8807 165TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3639
Mailing Address - Country:US
Mailing Address - Phone:347-670-7429
Mailing Address - Fax:
Practice Address - Street 1:8807 165TH AVE
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-3639
Practice Address - Country:US
Practice Address - Phone:347-670-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor