Provider Demographics
NPI:1497416366
Name:STEVEN W KELLETT
Entity Type:Organization
Organization Name:STEVEN W KELLETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-847-8646
Mailing Address - Street 1:190 C ST NW
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-1328
Mailing Address - Country:US
Mailing Address - Phone:812-847-8646
Mailing Address - Fax:812-847-8761
Practice Address - Street 1:190 C ST NW
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-1328
Practice Address - Country:US
Practice Address - Phone:812-847-8646
Practice Address - Fax:812-847-8761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental