Provider Demographics
NPI:1982767240
Name:KELLEY, IVAN F III (DC)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:F
Last Name:KELLEY
Suffix:III
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 1:111 SE DOUGLAS ST STE F1
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4434
Mailing Address - Country:US
Mailing Address - Phone:541-265-5132
Mailing Address - Fax:
Practice Address - Street 1:111 SE DOUGLAS ST STE F1
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4434
Practice Address - Country:US
Practice Address - Phone:541-265-5132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000QGCVLMedicare ID - Type Unspecified