Provider Demographics
NPI:1508110503
Name:KELLY L MCKERAHAN D O A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KELLY L MCKERAHAN D O A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCKERAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-696-9566
Mailing Address - Street 1:25095 JEFFERSON AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9107
Mailing Address - Country:US
Mailing Address - Phone:951-696-9566
Mailing Address - Fax:951-696-9536
Practice Address - Street 1:25095 JEFFERSON AVE STE 202
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9107
Practice Address - Country:US
Practice Address - Phone:951-696-9566
Practice Address - Fax:951-696-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6780261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GQ212AOtherPTAN
CA1508110503Medicare UPIN