MEDICARE: KEOUGH CHIROPRACTIC, INC

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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1104026913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEOUGH CHIROPRACTIC, INC

Provider Business Mailing Address
First Line	:	12139 MOUNT VERNON AVE STE 100
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5519
Country	:	US
Telephone Number	:	909-783-4950
Fax Number	:	909-783-1008

Provider Business Practice Location Address
First Line	:	12139 MOUNT VERNON AVE STE 100
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5519
Country	:	US
Telephone Number	:	909-783-4950
Fax Number	:	909-783-1008

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KELLY PATRICK KEOUGH
Credential	:	DC
Telephone Number	:	909-783-4950

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	10/31/2008

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Directions to “KEOUGH CHIROPRACTIC, INC ” Practice Location

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