Healthcare Provider Details

I. General information

NPI: 1053422410
Provider Name (Legal Business Name): KELLY A FALLON DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 N. SANDBURG TERRACE SUITE 101
CHICAGO IL
60610
US

IV. Provider business mailing address

1658 W. DIVERSEY PKWY UNIT # 2
CHICAGO IL
60614
US

V. Phone/Fax

Practice location:
  • Phone: 312-944-4653
  • Fax: 312-944-0747
Mailing address:
  • Phone: 630-881-9183
  • Fax: 773-751-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9138
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: