MEDICARE: KELLI-JO RICHARD DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NP0017X	Pediatric Chiropractor	1954	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1954	OTHER	LA	LA CHIROPRACTIC LICENSE NUMBER

General Provider Information

NPI Number	:	1033712591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI-JO RICHARD DC

Provider Business Mailing Address
First Line	:	1913 W CONGRESS ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4433
Country	:	US
Telephone Number	:	337-240-6003
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 W CONGRESS ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4433
Country	:	US
Telephone Number	:	337-240-6003
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	10/10/2022

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