Provider Demographics
NPI:1093033573
Name:C KELLY FAMILY CLINIC, PA
Entity Type:Organization
Organization Name:C KELLY FAMILY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-214-6411
Mailing Address - Street 1:794 GENERATIONS DR., STE. 100
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130
Mailing Address - Country:US
Mailing Address - Phone:830-214-6411
Mailing Address - Fax:830-626-8800
Practice Address - Street 1:794 GENERATIONS DR., STE. 100
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-2460
Practice Address - Country:US
Practice Address - Phone:830-214-6411
Practice Address - Fax:830-626-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-09
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2151524-01Medicaid
TX215152402Medicaid
TXTXB106371Medicare PIN
TX2151524-01Medicaid