Provider Demographics
NPI:1710282744
Name:KELLYS ELITE BOUTIQUE, LLC
Entity Type:Organization
Organization Name:KELLYS ELITE BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-424-9655
Mailing Address - Street 1:1869 NILES CORTLAND RD., NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484
Mailing Address - Country:US
Mailing Address - Phone:877-424-9655
Mailing Address - Fax:866-423-1145
Practice Address - Street 1:1869 NILES CORTLAND RD., NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484
Practice Address - Country:US
Practice Address - Phone:877-424-9655
Practice Address - Fax:866-423-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-23
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies