Provider Demographics
NPI:1093229411
Name:PRESTON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PRESTON
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 1:500 GROTTO ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1754
Mailing Address - Country:US
Mailing Address - Phone:651-760-3236
Mailing Address - Fax:651-222-6025
Practice Address - Street 1:500 GROTTO STREET N
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-760-3236
Practice Address - Fax:651-222-6025
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor