Provider Demographics
NPI:1730405119
Name:KELLY-WISE, LLC
Entity type:Organization
Organization Name:KELLY-WISE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-645-0040
Mailing Address - Street 1:3680 LEONARDTOWN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3696
Mailing Address - Country:US
Mailing Address - Phone:301-645-0040
Mailing Address - Fax:301-645-0880
Practice Address - Street 1:3680 LEONARDTOWN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3696
Practice Address - Country:US
Practice Address - Phone:301-645-0040
Practice Address - Fax:301-645-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-11
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2720253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0163430306Medicaid
MD2626047-00Medicaid