Healthcare Provider Details

I. General information

NPI: 1275731069
Provider Name (Legal Business Name): BACK & NECK CLINIC OF EXETER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 SUNSET MANOR DR
BIRDSBORO PA
19508-1018
US

IV. Provider business mailing address

160 SUNSET MANOR DR
BIRDSBORO PA
19508-1018
US

V. Phone/Fax

Practice location:
  • Phone: 610-404-4442
  • Fax: 610-404-1057
Mailing address:
  • Phone: 610-404-4442
  • Fax: 610-404-1057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC005606L
License Number StatePA

VIII. Authorized Official

Name: DR. WILLIAM JAMES KELLY
Title or Position: OWNER
Credential: D.C.
Phone: 610-404-4442