Provider Demographics
NPI:1417151358
Name:KELLY, JAMES (LAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 S DUNSMUIR AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-4032
Mailing Address - Country:US
Mailing Address - Phone:310-991-1352
Mailing Address - Fax:310-937-9016
Practice Address - Street 1:2940 WESTWOOD BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4145
Practice Address - Country:US
Practice Address - Phone:310-991-1352
Practice Address - Fax:310-937-9016
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9902171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist