Provider Demographics
NPI:1760811798
Name:SANDAL KELLY PHD
Entity Type:Organization
Organization Name:SANDAL KELLY PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDAL
Authorized Official - Middle Name:ARLILLIAN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMVT
Authorized Official - Phone:702-255-0056
Mailing Address - Street 1:6531 PLUM ORCHARD CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-0966
Mailing Address - Country:US
Mailing Address - Phone:702-255-0056
Mailing Address - Fax:702-255-0076
Practice Address - Street 1:6531 PLUM ORCHARD CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89142-0966
Practice Address - Country:US
Practice Address - Phone:702-255-0056
Practice Address - Fax:702-255-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMFT 01002261QM1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health