Provider Demographics
NPI:1083749824
Name:KELLY'S PRIMARY CARE, INC
Entity Type:Organization
Organization Name:KELLY'S PRIMARY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:956-583-0141
Mailing Address - Street 1:2007 N CONWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572
Mailing Address - Country:US
Mailing Address - Phone:956-583-0141
Mailing Address - Fax:956-583-0143
Practice Address - Street 1:2009 N CONWAY AVE
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2965
Practice Address - Country:US
Practice Address - Phone:956-583-0141
Practice Address - Fax:956-583-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX006524305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185365701Medicaid
TX000017300Medicaid
TX001012821Medicaid