Provider Demographics
NPI:1922577022
Name:THE KELLY CODE, LLC
Entity Type:Organization
Organization Name:THE KELLY CODE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS
Authorized Official - Phone:252-412-1963
Mailing Address - Street 1:205 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5015
Mailing Address - Country:US
Mailing Address - Phone:252-412-1963
Mailing Address - Fax:252-364-2248
Practice Address - Street 1:3219 LANDMARK ST STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7688
Practice Address - Country:US
Practice Address - Phone:252-412-1963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730457193Medicaid