Provider Demographics
NPI:1942231287
Name:J & S KELLY GALESBURG L.L.C.
Entity Type:Organization
Organization Name:J & S KELLY GALESBURG L.L.C.
Other - Org Name:KELLY'S MEDICAL EQUIPMENT & SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-386-1553
Mailing Address - Street 1:730 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1621
Mailing Address - Country:US
Mailing Address - Phone:563-386-1553
Mailing Address - Fax:563-391-7702
Practice Address - Street 1:1968 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1325
Practice Address - Country:US
Practice Address - Phone:309-341-1117
Practice Address - Fax:309-341-1015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J&S KELLY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2012-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid