Provider Demographics
NPI:1548362130
Name:BUTH, KELLY T (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:T
Last Name:BUTH
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 11697
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427
Mailing Address - Country:US
Mailing Address - Phone:928-763-9308
Mailing Address - Fax:
Practice Address - Street 1:4470 HWY 95
Practice Address - Street 2:STE 9
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9101
Practice Address - Country:US
Practice Address - Phone:928-763-9308
Practice Address - Fax:928-758-7035
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2533111N00000X
TX4883111N00000X
AZ4462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0233570OtherBC/BS PREFERRED PROVIDER
AZT93279Medicare UPIN
AZAZ0233570OtherBC/BS PREFERRED PROVIDER