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General NPI Number Information
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NPI Number | 1821286527
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Entity Type | Organization
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Legal Business Name | KELLY CHIROPRACTIC CENTER OF WALLACE
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 03/20/2008
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Provider Practice Location Address
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Address Line | 112 MEDICAL VILLAGE DR SUITE A
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City | WALLACE
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State | NC
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Zip | 28466-1668
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Country | US
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Telephone | 910-285-9002
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1917
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City | CLINTON
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State | NC
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Zip | 28329-1917
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Country | US
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Telephone | 910-285-9002
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHAD GARRETT KELLY
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Credential | D.C.
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Telephone | 910-214-6887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2714
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License Number State | NC
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