=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265299481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY LOW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2024
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6416 W HIGGINS AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60656-2285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-774-6771
-----------------------------------------------------
Fax | 773-774-6789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1135 NEWBERRY AVE
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-903-9208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KELLY LOW
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 708-903-9208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------