Provider Demographics
NPI:1104877463
Name:KELLY, JOSEPH (DC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 DUTCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009
Mailing Address - Country:US
Mailing Address - Phone:724-495-3313
Mailing Address - Fax:724-495-3329
Practice Address - Street 1:4425 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009
Practice Address - Country:US
Practice Address - Phone:724-495-3313
Practice Address - Fax:724-495-3329
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA066572Medicare ID - Type Unspecified
U93623Medicare UPIN