MEDICARE: KELLY CHIROPRACTIC CENTER OF WALLACE

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	2714	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0841K	OTHER	BLUE CROSS BLUE SHIELD
4	0845C	OTHER	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1821286527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY CHIROPRACTIC CENTER OF WALLACE

Provider Business Mailing Address
First Line	:	PO BOX 1917
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28329-1917
Country	:	US
Telephone Number	:	910-285-9002
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 MEDICAL VILLAGE DR
Second Line	:	SUITE A
City	:	WALLACE
State	:	NC
Zip	:	28466-1668
Country	:	US
Telephone Number	:	910-285-9002
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHAD GARRETT KELLY
Credential	:	D.C.
Telephone Number	:	910-214-6887

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	03/20/2008

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Directions to “KELLY CHIROPRACTIC CENTER OF WALLACE ” Practice Location

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