Provider Demographics
NPI:1821148834
Name:KELLEY, GREG (DC)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:KELLEY
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 1:1077 CASS ST STE C
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4551
Mailing Address - Country:US
Mailing Address - Phone:831-373-5636
Mailing Address - Fax:
Practice Address - Street 1:1077 CASS ST STE C
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4551
Practice Address - Country:US
Practice Address - Phone:831-373-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC206580OtherBLUE SHIELD OF CA PIN
CA350046182OtherRAILROAD PROVIDER NUMBER
CADC2065800Medicare PIN