Provider Demographics
NPI:1275924409
Name:KELLY, JOSEPH LOUIS
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LOUIS
Last Name:KELLY
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 1:634 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:KOHLER
Mailing Address - State:WI
Mailing Address - Zip Code:53044-1618
Mailing Address - Country:US
Mailing Address - Phone:920-452-2737
Mailing Address - Fax:
Practice Address - Street 1:634 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:KOHLER
Practice Address - State:WI
Practice Address - Zip Code:53044-1618
Practice Address - Country:US
Practice Address - Phone:920-452-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications