Provider Demographics
NPI:1467577585
Name:KELLY, WILLIAM T (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:525 HIGHWAY 70
Mailing Address - Street 2:SUITE A6
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5847
Mailing Address - Country:US
Mailing Address - Phone:732-370-8160
Mailing Address - Fax:732-370-8161
Practice Address - Street 1:525 HIGHWAY 70
Practice Address - Street 2:SUITE A6
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5847
Practice Address - Country:US
Practice Address - Phone:732-370-8160
Practice Address - Fax:732-370-8161
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00136800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ422411Medicare UPIN