Provider Demographics
NPI:1174522635
Name:KELLEY, GARY C (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8720 TAAJANAR CT
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-2625
Mailing Address - Country:US
Mailing Address - Phone:916-988-8645
Mailing Address - Fax:916-987-7426
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:STE 701
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2927
Practice Address - Country:US
Practice Address - Phone:916-786-5828
Practice Address - Fax:916-786-5055
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 15262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA350043160OtherMEDICARE RAILROAD
CA350043160OtherMEDICARE RAILROAD