Provider Demographics
NPI:1821396078
Name:KELLY CHIROPRACTIC, PS
Entity Type:Organization
Organization Name:KELLY CHIROPRACTIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DIBCN
Authorized Official - Phone:360-882-0767
Mailing Address - Street 1:6700 NE 162ND AVE
Mailing Address - Street 2:SUITE 415
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3858
Mailing Address - Country:US
Mailing Address - Phone:360-882-0767
Mailing Address - Fax:
Practice Address - Street 1:6700 NE 162ND AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-3858
Practice Address - Country:US
Practice Address - Phone:360-882-0767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003084111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty