Provider Demographics
NPI:1184055873
Name:LUMBARD, KELLEY (DC)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:
Last Name:LUMBARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:SCHAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:4616 BLACK WOLF RUN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-3400
Mailing Address - Country:US
Mailing Address - Phone:612-578-6001
Mailing Address - Fax:
Practice Address - Street 1:1519 CENTRAL PKWY STE 260
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2488
Practice Address - Country:US
Practice Address - Phone:612-578-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184055873Medicaid
WIK400137364Medicare PIN
WIK100124233Medicare PIN