=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275731069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK & NECK CLINIC OF EXETER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 SUNSET MANOR DR
-----------------------------------------------------
City | BIRDSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19508-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-404-4442
-----------------------------------------------------
Fax | 610-404-1057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 SUNSET MANOR DR
-----------------------------------------------------
City | BIRDSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19508-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-404-4442
-----------------------------------------------------
Fax | 610-404-1057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM JAMES KELLY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 610-404-4442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC005606L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------