MEDICARE: OMNI KELLY

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	106S00000X	Behavior Technician		SC

General Provider Information

NPI Number	:	1720921844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMNI KELLY

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 ARBORLAND WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-2201
Country	:	US
Telephone Number	:	864-520-1614
Fax Number	:

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

Provider Enumeration Date	:	04/13/2026
Last Update Date	:	04/13/2026

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Directions to “ OMNI KELLY ” Practice Location

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