Provider Demographics
NPI:1972526663
Name:MCCOY GROSS, KELLY A (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:MCCOY GROSS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8999 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-4260
Mailing Address - Country:US
Mailing Address - Phone:314-428-2225
Mailing Address - Fax:314-428-3338
Practice Address - Street 1:8999 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-4260
Practice Address - Country:US
Practice Address - Phone:314-428-2225
Practice Address - Fax:314-428-3338
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO672752OtherACN GROUP
MO02-53978OtherUNITEDHEALTHCARE
MO1060746OtherCIGNA
MO199416OtherBLUE CROSS BLUE SHIELD
MO199416OtherBLUE CROSS BLUE SHIELD
MO672752OtherACN GROUP