Provider Demographics
NPI:1720074156
Name:CALLOWAY, KELLY ANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:CALLOWAY
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 1:228 N CHILES ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1606
Mailing Address - Country:US
Mailing Address - Phone:217-854-3644
Mailing Address - Fax:217-854-7107
Practice Address - Street 1:228 N CHILES ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1606
Practice Address - Country:US
Practice Address - Phone:217-854-3644
Practice Address - Fax:217-854-7107
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV06260Medicare UPIN
IL212157Medicare ID - Type Unspecified