=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548305022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLEY CHIROPRACTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 02/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1503 LARSON ST
-----------------------------------------------------
City | BLOOMER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54724-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-568-4220
-----------------------------------------------------
Fax | 715-568-4201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1503 LARSON ST
-----------------------------------------------------
City | BLOOMER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54724-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-568-4220
-----------------------------------------------------
Fax | 715-568-4201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JODI SWARTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-568-4220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 2014-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------