Provider Demographics
NPI:1780636951
Name:KELSEY, CHARLES LAMOINE (D C)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAMOINE
Last Name:KELSEY
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10910 US HIGHWAY 24 W
Mailing Address - Street 2:UNIT A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8157
Mailing Address - Country:US
Mailing Address - Phone:260-432-8777
Mailing Address - Fax:
Practice Address - Street 1:10910 US HIGHWAY 24 W
Practice Address - Street 2:UNIT A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-8157
Practice Address - Country:US
Practice Address - Phone:260-432-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000637A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253370Medicaid
INP00475023Medicare PIN
INU20337Medicare UPIN
IN862110AMedicare PIN