Provider Demographics
NPI:1619425899
Name:KELLY, EUGENE JR
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 N TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-6363
Mailing Address - Country:US
Mailing Address - Phone:702-374-8500
Mailing Address - Fax:
Practice Address - Street 1:1180 N TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6363
Practice Address - Country:US
Practice Address - Phone:702-374-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker