Basic Information
| Provider Information | |||||||||
| NPI: | 1053422410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1658 W. DIVERSEY PKWY | ||||||||
| Address2: | UNIT # 2 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308819183 | ||||||||
| FaxNumber: | 7737510722 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 N. SANDBURG TERRACE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129444653 | ||||||||
| FaxNumber: | 3129440747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH9138 | FL | N | Chiropractic Providers | Chiropractor | 111N00000X | IL | Y | Chiropractic Providers | Chiropractor |
No ID Information.