MEDICARE: KELSEY PROSTHETICS ORTHOTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier		WI

General Provider Information

NPI Number	:	1164796496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELSEY PROSTHETICS ORTHOTICS LLC

Provider Business Mailing Address
First Line	:	6790 W LAYTON AVE
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53220-4571
Country	:	US
Telephone Number	:	414-282-3100
Fax Number	:	414-282-3101

Provider Business Practice Location Address
First Line	:	6790 W LAYTON AVE
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53220-4571
Country	:	US
Telephone Number	:	414-282-3100
Fax Number	:	414-282-3101

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BRIAN KELSEY
Credential	:	CPO
Telephone Number	:	414-282-3100

Provider Enumeration Date	:	03/05/2012
Last Update Date	:	10/08/2021

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