Provider Demographics
NPI:1831785385
Name:MAGUIRE, KELLY DEAN (DC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DEAN
Last Name:MAGUIRE
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 1:2515 CROSBY AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4553
Mailing Address - Country:US
Mailing Address - Phone:541-883-2225
Mailing Address - Fax:541-882-9388
Practice Address - Street 1:2515 CROSBY AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4553
Practice Address - Country:US
Practice Address - Phone:541-883-2225
Practice Address - Fax:541-882-9388
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6120111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6120OtherLICENSE