Provider Demographics
NPI:1467818971
Name:KELLY, JOE (RRT)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 VILLA AVE
Mailing Address - Street 2:# A
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1064
Mailing Address - Country:US
Mailing Address - Phone:559-326-3662
Mailing Address - Fax:
Practice Address - Street 1:584 VILLA AVE
Practice Address - Street 2:# A
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1064
Practice Address - Country:US
Practice Address - Phone:559-326-3662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30024227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered