=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083874846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MICHAEL KELLY DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2008
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15901 HAWTHORNE BLVD SUITE 420
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260-2655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-496-6104
-----------------------------------------------------
Fax | 805-496-6144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 E THOUSAND OAKS BLVD SUITE 420
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-496-6104
-----------------------------------------------------
Fax | 805-496-6144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC17725
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------