Provider Demographics
NPI:1437202819
Name:TERRI KELLEY
Entity Type:Organization
Organization Name:TERRI KELLEY
Other - Org Name:INNOVATIVE MOBILE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-626-9729
Mailing Address - Street 1:PO BOX 2966
Mailing Address - Street 2:1801 KATHERINE ST
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2966
Mailing Address - Country:US
Mailing Address - Phone:417-626-9729
Mailing Address - Fax:471-206-4113
Practice Address - Street 1:1801 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5888
Practice Address - Country:US
Practice Address - Phone:417-626-9729
Practice Address - Fax:471-206-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO309335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200021670AMedicaid
MO719136509Medicaid
KS200253180AMedicaid
MO719136509Medicaid
MOP00056490Medicare PIN
KS130574Medicare PIN
OK800522271Medicare PIN