Provider Demographics
NPI:1467956748
Name:KELLMARC HOME HEALTH THERAPIS
Entity Type:Organization
Organization Name:KELLMARC HOME HEALTH THERAPIS
Other - Org Name:KELLMARC HOME HEALTH THERAPIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUDAGNA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:281-265-5359
Mailing Address - Street 1:4771 SWEETWATER BLVD # 179
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3121
Mailing Address - Country:US
Mailing Address - Phone:281-265-5359
Mailing Address - Fax:
Practice Address - Street 1:1706 COLES FARM DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4257
Practice Address - Country:US
Practice Address - Phone:281-265-5359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105294251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health