Provider Demographics
NPI:1013298843
Name:KELLY, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11113 BIRCH HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-5037
Mailing Address - Country:US
Mailing Address - Phone:719-574-7781
Mailing Address - Fax:
Practice Address - Street 1:11113 BIRCH HOLLOW WAY
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-5037
Practice Address - Country:US
Practice Address - Phone:719-574-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSA-1258246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant