Provider Demographics
NPI:1912570862
Name:KELLY, BENJAMIN KENNETH (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KENNETH
Last Name:KELLY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FORT AVE
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2600
Mailing Address - Country:US
Mailing Address - Phone:240-362-3188
Mailing Address - Fax:
Practice Address - Street 1:101 FORT AVE
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2600
Practice Address - Country:US
Practice Address - Phone:240-362-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0016912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer