Provider Demographics
NPI:1598998858
Name:KELLEY, MARK (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:8455 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5066
Mailing Address - Country:US
Mailing Address - Phone:352-795-6225
Mailing Address - Fax:352-795-6065
Practice Address - Street 1:394 N SUNCOAST BLVD
Practice Address - Street 2:STE 40
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-5466
Practice Address - Country:US
Practice Address - Phone:352-795-6225
Practice Address - Fax:352-795-6065
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106898OtherMEDICARE ID