Healthcare Provider Details

I. General information

NPI: 1427520634
Provider Name (Legal Business Name): JUSTIN KELLY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8011 MARYLAND AVENUE
ST. LOUIS MO
63105
US

IV. Provider business mailing address

71 SAN TANA CT
CEDAR HILL MO
63016
US

V. Phone/Fax

Practice location:
  • Phone: 989-619-4839
  • Fax:
Mailing address:
  • Phone: 989-619-4839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number111NS0005X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: