Provider Demographics
NPI:1902878333
Name:KELLEY, KENNETH A (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:KELLEY
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:OR
Mailing Address - Zip Code:97378-0037
Mailing Address - Country:US
Mailing Address - Phone:503-843-3888
Mailing Address - Fax:503-843-4366
Practice Address - Street 1:639 W MAIN
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378
Practice Address - Country:US
Practice Address - Phone:503-843-3888
Practice Address - Fax:503-843-4366
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112941OtherKAISER PERMANENTE
OR112941OtherKAISER PERMANENTE
OR0000QGBLPMedicare ID - Type Unspecified