Provider Demographics
NPI:1912132978
Name:CHELLIS, TARA LORRAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LORRAINE
Last Name:CHELLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:LORRAINE
Other - Last Name:BISACCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:405 N MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6841
Mailing Address - Country:US
Mailing Address - Phone:843-871-7775
Mailing Address - Fax:843-871-7375
Practice Address - Street 1:405 N MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6841
Practice Address - Country:US
Practice Address - Phone:843-871-7775
Practice Address - Fax:843-871-7375
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3431111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor