Healthcare Provider Details

I. General information

NPI: 1134120058
Provider Name (Legal Business Name): CORVIN KELLY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74976 US HIGHWAY 111
INDIAN WELLS CA
92210-7117
US

IV. Provider business mailing address

74976 US HIGHWAY 111
INDIAN WELLS CA
92210-7117
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-5455
  • Fax: 760-568-5444
Mailing address:
  • Phone: 760-568-5455
  • Fax: 760-568-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC26074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: