Provider Demographics
NPI:1033400759
Name:KELLY IMAGING GROUP, LLC
Entity Type:Organization
Organization Name:KELLY IMAGING GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER, VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-248-4080
Mailing Address - Street 1:PO BOX 26565
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-1565
Mailing Address - Country:US
Mailing Address - Phone:864-248-4080
Mailing Address - Fax:
Practice Address - Street 1:112 COSGROVE LN
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4106
Practice Address - Country:US
Practice Address - Phone:864-248-4080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH460012471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty