Provider Demographics
NPI:1225529720
Name:KELLEY, ADAM ROSARIO
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:ROSARIO
Last Name:KELLEY
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 1:2604 S MAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2338
Mailing Address - Country:US
Mailing Address - Phone:541-570-1728
Mailing Address - Fax:
Practice Address - Street 1:2604 S MAIN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2338
Practice Address - Country:US
Practice Address - Phone:541-570-1728
Practice Address - Fax:541-405-4020
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR619337-93261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)