Provider Demographics
NPI:1184781981
Name:KELLY CHIROPRACTIC CENTER, P.A.
Entity type:Organization
Organization Name:KELLY CHIROPRACTIC CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-757-8989
Mailing Address - Street 1:1460 RITCHIE HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2730
Mailing Address - Country:US
Mailing Address - Phone:410-757-8989
Mailing Address - Fax:410-757-9139
Practice Address - Street 1:1460 RITCHIE HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2730
Practice Address - Country:US
Practice Address - Phone:410-757-8989
Practice Address - Fax:410-757-9139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSO1283111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherTAX ID
MD496LMedicare ID - Type Unspecified
MDT59571Medicare UPIN