Provider Demographics
NPI:1245377282
Name:KELLY, GLENN RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RICHARD
Last Name:KELLY
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 1:100 ROTUNDA DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-1966
Mailing Address - Country:US
Mailing Address - Phone:703-627-7553
Mailing Address - Fax:
Practice Address - Street 1:100 ROTUNDA DR
Practice Address - Street 2:
Practice Address - City:STEPHENSON
Practice Address - State:VA
Practice Address - Zip Code:22656-1966
Practice Address - Country:US
Practice Address - Phone:703-627-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010455985111NN0400X, 111NR0200X, 111NS0005X, 111NX0100X, 111NX0800X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NR0200XChiropractic ProvidersChiropractorRadiology
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic