Healthcare Provider Details

I. General information

NPI: 1639114366
Provider Name (Legal Business Name): KELLY JAY KADOLPH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 MILLER ST
BETHANY MO
64424-2716
US

IV. Provider business mailing address

PO BOX 527
BETHANY MO
64424-0527
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-3312
  • Fax: 660-425-3438
Mailing address:
  • Phone: 660-425-3312
  • Fax: 660-425-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number005205
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: