Provider Demographics
NPI:1326374687
Name:KELLY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:KELLY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:JOSEPHINE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-251-4006
Mailing Address - Street 1:4223 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2901
Mailing Address - Country:US
Mailing Address - Phone:773-251-4006
Mailing Address - Fax:773-634-8272
Practice Address - Street 1:4223 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-2901
Practice Address - Country:US
Practice Address - Phone:773-251-4006
Practice Address - Fax:773-634-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011438111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty