Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 01-05763 | KS |
Y | 111N00000X | Chiropractor | 4396 | OK |
N | 111NP0017X | Pediatric Chiropractor | 01-05763 | KS |
NPI | 1134585144 |
---|---|
Provider Name | Dr. Kelly J Callaway |
First Address | Tahlequah, OK 74464-6289 |
Second Address | Tahlequah, OK 74464-4750 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/01/2016 |
Last Update Date | 27/01/2021 |