Provider Demographics
NPI:1306972427
Name:STORK, KELLY S (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:S
Last Name:STORK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:MIX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2011 N LOCUST GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1827
Mailing Address - Country:US
Mailing Address - Phone:208-888-8797
Mailing Address - Fax:208-888-8799
Practice Address - Street 1:2011 N LOCUST GROVE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1827
Practice Address - Country:US
Practice Address - Phone:208-888-8797
Practice Address - Fax:208-888-8799
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1096111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV04090Medicare UPIN