Provider Demographics
NPI:1578702833
Name:J.KELLEY SALON
Entity Type:Organization
Organization Name:J.KELLEY SALON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLIGIST
Authorized Official - Phone:207-846-9696
Mailing Address - Street 1:81 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6744
Mailing Address - Country:US
Mailing Address - Phone:207-846-9696
Mailing Address - Fax:
Practice Address - Street 1:81 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6744
Practice Address - Country:US
Practice Address - Phone:207-846-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECO13731335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier