1003065202 NPI number — DR. JOHN HOWARD KELLENBERGER SR. DC

Table of content: DR. JOHN HOWARD KELLENBERGER SR. DC (NPI 1003065202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003065202 NPI number — DR. JOHN HOWARD KELLENBERGER SR. DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLENBERGER
Provider First Name:
JOHN
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003065202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
256 CAVILLER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33917-2985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-656-0091
Provider Business Mailing Address Fax Number:
239-489-1314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14090 METROPOLIS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-489-4100
Provider Business Practice Location Address Fax Number:
239-489-1314
Provider Enumeration Date:
09/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH2118 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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