MEDICARE: DR. KELLY WALLIS 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	CH10990	FL

General Provider Information

NPI Number	:	1952724395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY WALLIS D.C.

Provider Business Mailing Address
First Line	:	6309 CORPORATE CT
Second Line	:	STE. 110
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3538
Country	:	US
Telephone Number	:	239-433-1011
Fax Number	:	239-433-3737

Provider Business Practice Location Address
First Line	:	6309 CORPORATE CT
Second Line	:	STE. 110
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3538
Country	:	US
Telephone Number	:	239-433-1011
Fax Number	:	239-433-3737

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

Provider Enumeration Date	:	01/21/2014
Last Update Date	:	01/21/2014

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