Healthcare Provider Details

I. General information

NPI: 1932264900
Provider Name (Legal Business Name): CHIROPRACTIC INJURY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 SHIRLEY AVE
REVERE MA
02151-3258
US

IV. Provider business mailing address

199 SHIRLEY AVE
REVERE MA
02151-3258
US

V. Phone/Fax

Practice location:
  • Phone: 781-485-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2403
License Number StateMA

VIII. Authorized Official

Name: JEFFREY I KELLER
Title or Position: DR. JEFFREY KELLER
Credential: D.C.
Phone: 781-485-3801