Provider Demographics
NPI:1831351998
Name:KELLY CHIROPRACTIC INC
Entity type:Organization
Organization Name:KELLY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-568-4544
Mailing Address - Street 1:74976 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-7117
Mailing Address - Country:US
Mailing Address - Phone:760-568-4544
Mailing Address - Fax:760-568-4555
Practice Address - Street 1:74976 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-7117
Practice Address - Country:US
Practice Address - Phone:760-568-4544
Practice Address - Fax:760-568-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty