MEDICARE: DENISE L. KELLEY GANTT D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	8093	AZ

General Provider Information

NPI Number	:	1174853428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE L. KELLEY GANTT D.C.

Provider Business Mailing Address
First Line	:	416 W 11TH ST
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85281-5516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3510 N 24TH ST
Second Line	:	SUITE B
City	:	PHOENIX
State	:	AZ
Zip	:	85016-6608
Country	:	US
Telephone Number	:	602-402-1904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2010
Last Update Date	:	02/19/2010

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