Provider Demographics
NPI:1003535386
Name:KELLY, TIM RAY
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:RAY
Last Name:KELLY
Suffix:
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 1:1221 NW HIGHWAY 101 STE A
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-3351
Mailing Address - Country:US
Mailing Address - Phone:971-727-5471
Mailing Address - Fax:
Practice Address - Street 1:1221 NW HIGHWAY 101 STE A
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-3351
Practice Address - Country:US
Practice Address - Phone:442-244-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106995175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist