Provider Demographics
NPI:1417419904
Name:KELLCO MEDICAL EQUIPMENT
Entity Type:Organization
Organization Name:KELLCO MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-237-7223
Mailing Address - Street 1:1903 TURNER MCCALL BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3366
Mailing Address - Country:US
Mailing Address - Phone:706-237-7223
Mailing Address - Fax:
Practice Address - Street 1:1903 TURNER MCCALL BLVD SE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3366
Practice Address - Country:US
Practice Address - Phone:706-237-7223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054860421OtherSTATE OF GEORGIA