Provider Demographics
NPI:1003431164
Name:KELLY, JOHN I
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E CHOCCOLOCCO ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203-1222
Mailing Address - Country:US
Mailing Address - Phone:256-831-4601
Mailing Address - Fax:256-835-3386
Practice Address - Street 1:118 E CHOCCOLOCCO ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203-1222
Practice Address - Country:US
Practice Address - Phone:256-831-4601
Practice Address - Fax:256-835-3386
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer