Provider Demographics
NPI:1083973903
Name:KRISTOPHER J. KELLY LLC
Entity Type:Organization
Organization Name:KRISTOPHER J. KELLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-893-4883
Mailing Address - Street 1:5655 MONCLOVA RD
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1870
Mailing Address - Country:US
Mailing Address - Phone:419-893-4883
Mailing Address - Fax:419-893-2312
Practice Address - Street 1:5655 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1870
Practice Address - Country:US
Practice Address - Phone:419-893-4883
Practice Address - Fax:419-893-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-12
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087489174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty