Provider Demographics
NPI:1982889093
Name:KELLIE WOOTEN
Entity Type:Organization
Organization Name:KELLIE WOOTEN
Other - Org Name:KELLIE JEFFREY, D.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-386-0340
Mailing Address - Street 1:102 MOSHEIM ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4908
Mailing Address - Country:US
Mailing Address - Phone:830-386-0340
Mailing Address - Fax:
Practice Address - Street 1:102 MOSHEIM ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4908
Practice Address - Country:US
Practice Address - Phone:830-386-0340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00211WMedicare PIN