Provider Demographics
NPI:1801839733
Name:KELLY, KEVIN J (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
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 1:1 PARKVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2056
Mailing Address - Country:US
Mailing Address - Phone:732-721-1116
Mailing Address - Fax:732-525-0932
Practice Address - Street 1:1 PARKVIEW BLVD
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-2056
Practice Address - Country:US
Practice Address - Phone:732-721-1116
Practice Address - Fax:732-525-0932
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00329500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ452474W58Medicare PIN
NJKE452474Medicare UPIN