Provider Demographics
NPI:1205828845
Name:MASON, KELLI S (DC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:S
Last Name:MASON
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 1:1807 4TH CORSO
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NEBRASKA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68410-2679
Mailing Address - Country:US
Mailing Address - Phone:402-874-9044
Mailing Address - Fax:844-270-5928
Practice Address - Street 1:1541 OGDEN RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5683
Practice Address - Country:US
Practice Address - Phone:970-252-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1028111N00000X
CO0008024111N00000X
SC2438111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8404OtherGROUP PIN
SCCH2438Medicaid
SCCH2438Medicaid
SC8404OtherGROUP PIN