Provider Demographics
NPI:1124106596
Name:KELLY, MICHAEL DAVID (DC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
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 1:160 S BLOOMINGDALE RD
Mailing Address - Street 2:STE D
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1455
Mailing Address - Country:US
Mailing Address - Phone:630-893-7313
Mailing Address - Fax:630-893-7453
Practice Address - Street 1:132 S RIDGE AVE
Practice Address - Street 2:UNIT B
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1216
Practice Address - Country:US
Practice Address - Phone:630-893-7313
Practice Address - Fax:630-893-7453
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006619111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor