Provider Demographics
NPI:1770558975
Name:KELTY, ROBERT M (DC, PC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:KELTY
Suffix:
Gender:M
Credentials:DC, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E PINE ST
Mailing Address - Street 2:#101
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2400
Mailing Address - Country:US
Mailing Address - Phone:541-664-6636
Mailing Address - Fax:541-664-7071
Practice Address - Street 1:650 E PINE ST
Practice Address - Street 2:#101
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2400
Practice Address - Country:US
Practice Address - Phone:541-664-6636
Practice Address - Fax:541-664-7071
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR111920Medicare PIN
ORT67784Medicare UPIN