Provider Demographics
NPI:1578524203
Name:KELO, MICHAEL J (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:KELO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11801 BRAYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5303
Mailing Address - Country:US
Mailing Address - Phone:804-366-8518
Mailing Address - Fax:804-778-4522
Practice Address - Street 1:11928 IRON BRIDGE PLZ
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1441
Practice Address - Country:US
Practice Address - Phone:804-366-8518
Practice Address - Fax:804-778-4522
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VASTF191889Medicaid