MEDICARE: DR. KELLY T. BUTH 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	2533	MN
2	111N00000X	Chiropractor	4883	TX
3	111N00000X	Chiropractor	4462	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0233570	OTHER	AZ	BC/BS PREFERRED PROVIDER

General Provider Information

NPI Number	:	1548362130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY T. BUTH D.C.

Provider Business Mailing Address
First Line	:	PO BOX 11697
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427
Country	:	US
Telephone Number	:	928-763-9308
Fax Number	:

Provider Business Practice Location Address
First Line	:	4470 HWY 95
Second Line	:	STE 9
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9101
Country	:	US
Telephone Number	:	928-763-9308
Fax Number	:	928-758-7035

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	08/13/2020

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