Provider Demographics
NPI:1871532739
Name:DETRICK & KELLY CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:DETRICK & KELLY CHIROPRACTIC CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:724-838-7700
Mailing Address - Street 1:125 E OTTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-2509
Mailing Address - Country:US
Mailing Address - Phone:724-838-7700
Mailing Address - Fax:724-838-7200
Practice Address - Street 1:125 E OTTERMAN ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2509
Practice Address - Country:US
Practice Address - Phone:724-838-7700
Practice Address - Fax:724-838-7200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007066L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA410013OtherHEALTH AMERICA
PA216189OtherUPMC
PA427398OtherBLUE SHIELD
PA1813203Medicaid
PA5840690OtherAETNA
PA5840690OtherAETNA