Provider Demographics
NPI:1184021347
Name:CHARLES E.KELLY & COMPANY
Entity Type:Organization
Organization Name:CHARLES E.KELLY & COMPANY
Other - Org Name:TIPPIN BANK & TRUST COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MARKET COMMUNICATION SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:SR
Authorized Official - Credentials:DOC
Authorized Official - Phone:912-739-1122
Mailing Address - Street 1:409 OAK ST
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-1351
Mailing Address - Country:US
Mailing Address - Phone:912-739-1122
Mailing Address - Fax:
Practice Address - Street 1:409 OAK ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1351
Practice Address - Country:US
Practice Address - Phone:912-739-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENVILLE BANK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP1600X, 251B00000X, 251S00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1399374OtherGATEWAY AUTHORITY