Provider Demographics
NPI:1962495143
Name:REAGAN, KELLY VERNON (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:VERNON
Last Name:REAGAN
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 1:300 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1922
Mailing Address - Country:US
Mailing Address - Phone:563-382-4411
Mailing Address - Fax:563-382-2124
Practice Address - Street 1:300 E WATER ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1922
Practice Address - Country:US
Practice Address - Phone:563-382-4411
Practice Address - Fax:563-382-2124
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05825111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1119982Medicaid
IA56367Medicare ID - Type Unspecified