Provider Demographics
NPI:1104023043
Name:KELLY-SCISM LLC
Entity Type:Organization
Organization Name:KELLY-SCISM LLC
Other - Org Name:EZ IN AND OUT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-365-7137
Mailing Address - Street 1:110 OAKWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1958
Mailing Address - Country:US
Mailing Address - Phone:800-365-7137
Mailing Address - Fax:336-714-2671
Practice Address - Street 1:110 OAKWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1958
Practice Address - Country:US
Practice Address - Phone:800-365-7137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC18241245OtherTPIN