Healthcare Provider Details

I. General information

NPI: 1831351998
Provider Name (Legal Business Name): KELLY CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
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: 760-568-4544
  • Fax: 760-568-4555
Mailing address:
  • Phone: 760-568-4544
  • Fax: 760-568-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CORVIN KELLY
Title or Position: OWNER
Credential: DC
Phone: 760-568-4544