Provider Demographics
NPI:1972629012
Name:BUCKLEY, KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1710
Mailing Address - Country:US
Mailing Address - Phone:631-754-4333
Mailing Address - Fax:631-754-3833
Practice Address - Street 1:755 PULASKI RD
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1710
Practice Address - Country:US
Practice Address - Phone:631-754-4333
Practice Address - Fax:631-754-3833
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009978-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor