Provider Demographics
NPI:1669559993
Name:KELLERMAN, NICOLAS L (DC)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:L
Last Name:KELLERMAN
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 1:4010 SANDY BROOK DR.
Mailing Address - Street 2:103
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665
Mailing Address - Country:US
Mailing Address - Phone:512-258-9355
Mailing Address - Fax:512-236-5238
Practice Address - Street 1:4010 SANDY BROOK DR.
Practice Address - Street 2:103
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-258-9355
Practice Address - Fax:512-236-5238
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211477Medicare ID - Type Unspecified