Provider Demographics
NPI:1184946436
Name:WATFORD, KELLEY JO (DC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JO
Last Name:WATFORD
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:PO BOX 76204
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80970-6204
Mailing Address - Country:US
Mailing Address - Phone:719-629-8333
Mailing Address - Fax:
Practice Address - Street 1:128 SWOPE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5833
Practice Address - Country:US
Practice Address - Phone:719-629-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31567111N00000X
CO6875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor