Provider Demographics
NPI:1679752505
Name:BRIELLE E. KELLY, L.AC., INC.
Entity Type:Organization
Organization Name:BRIELLE E. KELLY, L.AC., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DIPLOM
Authorized Official - Phone:6502-596-5616
Mailing Address - Street 1:10 EL CAMINO REAL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 EL CAMINO REAL
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2451
Practice Address - Country:US
Practice Address - Phone:650-596-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-27
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty