Provider Demographics
NPI:1962638510
Name:ZOLLO, KELLY R (LPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:ZOLLO
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12353 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8305
Mailing Address - Country:US
Mailing Address - Phone:562-484-3385
Mailing Address - Fax:562-484-0269
Practice Address - Street 1:12353 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-8305
Practice Address - Country:US
Practice Address - Phone:562-484-3385
Practice Address - Fax:562-484-0269
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30755167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
1512013461Medicare UPIN
CA1512013461Medicare PIN