Provider Demographics
NPI:1215080619
Name:KELLEY, PATRICK JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:KELLEY
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 1:706 PINENECK RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1223
Mailing Address - Country:US
Mailing Address - Phone:516-390-3991
Mailing Address - Fax:516-937-1117
Practice Address - Street 1:297 BROADWAY
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-3706
Practice Address - Country:US
Practice Address - Phone:516-937-1115
Practice Address - Fax:516-937-1117
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008472-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX86451Medicare ID - Type Unspecified