Provider Demographics
NPI:1346499928
Name:MIKE KELO PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:MIKE KELO PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KELO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:804-366-8518
Mailing Address - Street 1:12212 BRANDERS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1626
Mailing Address - Country:US
Mailing Address - Phone:804-425-4545
Mailing Address - Fax:804-425-4546
Practice Address - Street 1:12212 BRANDERS CREEK DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1626
Practice Address - Country:US
Practice Address - Phone:804-425-4545
Practice Address - Fax:804-778-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
VA2305002847261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VASTF191889Medicaid