Provider Demographics
NPI:1407330632
Name:SHARON KELLY LMT, INC.
Entity Type:Organization
Organization Name:SHARON KELLY LMT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:727-301-5724
Mailing Address - Street 1:801 W BAY DR STE 500
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3220
Mailing Address - Country:US
Mailing Address - Phone:727-301-5724
Mailing Address - Fax:
Practice Address - Street 1:801 W BAY DR STE 500
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3220
Practice Address - Country:US
Practice Address - Phone:727-301-5724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
471312075OtherOPTUM HEALTH