Provider Demographics
NPI:1801006515
Name:KELLY, KEVIN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
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 1:20 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2918
Mailing Address - Country:US
Mailing Address - Phone:207-594-0000
Mailing Address - Fax:207-596-7131
Practice Address - Street 1:20 SUMMER ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2918
Practice Address - Country:US
Practice Address - Phone:207-594-0000
Practice Address - Fax:207-596-7131
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR 1449111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME187560000Medicaid