Provider Demographics
NPI:1427520634
Name:KELLY, JUSTIN (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
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 1:71 SAN TANA CT
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63016
Mailing Address - Country:US
Mailing Address - Phone:989-619-4839
Mailing Address - Fax:
Practice Address - Street 1:8011 MARYLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105
Practice Address - Country:US
Practice Address - Phone:989-619-4839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111NS0005X111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician