Provider Demographics
NPI:1508395476
Name:GEORGE, KELLY (ATHLETIC TRAINER)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 RED BIRD LANE
Mailing Address - Street 2:CAMPUS BOX 10611/ ATHLETIC TRAINING
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 RED BIRD LANE
Practice Address - Street 2:CAMPUS BOX 10611/ ATHLETIC TRAINING
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77710
Practice Address - Country:US
Practice Address - Phone:559-730-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT69542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer