Healthcare Provider Details

I. General information

NPI: 1407886153
Provider Name (Legal Business Name): KELLY PATRICK KEOUGH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12139 MOUNT VERNON AVE STE 100
GRAND TERRACE CA
92313-5519
US

IV. Provider business mailing address

1944 COUNTRY CLUB DR
REDLANDS CA
92373-7306
US

V. Phone/Fax

Practice location:
  • Phone: 909-783-4950
  • Fax: 909-783-1008
Mailing address:
  • Phone: 909-793-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number13815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: