MEDICARE: KELLY L REILLY

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	225700000X	Massage Therapist	2006010875	MO

General Provider Information

NPI Number	:	1700492147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L REILLY

Provider Business Mailing Address
First Line	:	555 N HARRISON AVE APT 2W
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3969
Country	:	US
Telephone Number	:	314-303-3161
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 N HARRISON AVE APT 2W
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3969
Country	:	US
Telephone Number	:	314-303-3161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	09/21/2020

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Directions to “ KELLY L REILLY ” Practice Location

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