Provider Demographics
NPI:1689083412
Name:KELSO, ALAN (HAS)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:KELSO
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4442
Mailing Address - Country:US
Mailing Address - Phone:904-264-0075
Mailing Address - Fax:904-264-0136
Practice Address - Street 1:4131 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG. 18
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4326
Practice Address - Country:US
Practice Address - Phone:904-264-0075
Practice Address - Fax:904-264-0136
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4875237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist