Provider Demographics
NPI:1659666402
Name:KELLY, MICHAL (L AC, MSTOM)
Entity Type:Individual
Prefix:MS
First Name:MICHAL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:L AC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12272 N FENTON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9614
Mailing Address - Country:US
Mailing Address - Phone:810-714-5556
Mailing Address - Fax:810-714-5455
Practice Address - Street 1:12272 N FENTON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9614
Practice Address - Country:US
Practice Address - Phone:810-714-5556
Practice Address - Fax:810-714-5455
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000838171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist