Provider Demographics
NPI:1548277957
Name:KELLY, PATRICK JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:KELLY
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 1:8332 PARK PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7304
Mailing Address - Country:US
Mailing Address - Phone:901-486-3559
Mailing Address - Fax:
Practice Address - Street 1:8332 PARK PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7304
Practice Address - Country:US
Practice Address - Phone:901-486-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000002085111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39738971Medicare PIN
V08978Medicare UPIN