Provider Demographics
NPI:1922117670
Name:REMILLARD, KELLY DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAVID
Last Name:REMILLARD
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 1:1122 W DIVIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1202
Mailing Address - Country:US
Mailing Address - Phone:701-258-5058
Mailing Address - Fax:701-258-1041
Practice Address - Street 1:1122 W DIVIDE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1202
Practice Address - Country:US
Practice Address - Phone:701-258-5058
Practice Address - Fax:701-258-1041
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25373OtherBCBS PIN NUMBER
ND13407Medicaid
ND13407Medicaid
ND711345Medicare PIN