Provider Demographics
NPI:1144739988
Name:KELLY COVE INC
Entity Type:Organization
Organization Name:KELLY COVE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-801-0773
Mailing Address - Street 1:3110 MOUNT VERNON AVE APT 1206
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22305-2654
Mailing Address - Country:US
Mailing Address - Phone:703-801-0773
Mailing Address - Fax:
Practice Address - Street 1:3110 MOUNT VERNON AVE APT 1206
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-2654
Practice Address - Country:US
Practice Address - Phone:703-801-0773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705097760332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies