Provider Demographics
NPI:1275996373
Name:MCKELLY, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MCKELLY
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 1:43839 15TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4756
Mailing Address - Country:US
Mailing Address - Phone:661-726-3219
Mailing Address - Fax:661-951-3192
Practice Address - Street 1:43839 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4756
Practice Address - Country:US
Practice Address - Phone:661-726-3219
Practice Address - Fax:661-951-3192
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13334227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified