Provider Demographics
NPI:1902100639
Name:GOLOB, KELLY CHRISTOPHER (DC)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:CHRISTOPHER
Last Name:GOLOB
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 1:128 D ST SW STE A
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4064
Mailing Address - Country:US
Mailing Address - Phone:360-570-9580
Mailing Address - Fax:360-570-9583
Practice Address - Street 1:128 D ST SW STE A
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4064
Practice Address - Country:US
Practice Address - Phone:360-570-9580
Practice Address - Fax:360-570-9583
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60198422111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor