Provider Demographics
NPI:1053422410
Name:FALLON, KELLY A (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:FALLON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 W. DIVERSEY PKWY
Mailing Address - Street 2:UNIT # 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:630-881-9183
Mailing Address - Fax:773-751-0722
Practice Address - Street 1:1360 N. SANDBURG TERRACE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610
Practice Address - Country:US
Practice Address - Phone:312-944-4653
Practice Address - Fax:312-944-0747
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9138111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV06606Medicare UPIN