Healthcare Provider Details

I. General information

NPI: 1962421289
Provider Name (Legal Business Name): KELLIE JEAN GILLIS DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S 11TH ST
GLADSTONE MI
49837-1504
US

IV. Provider business mailing address

8 S 11TH ST
GLADSTONE MI
49837-1504
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-2225
  • Fax: 906-428-9778
Mailing address:
  • Phone: 906-428-2225
  • Fax: 906-428-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: