MEDICARE: KELLY HARRIS

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	247200000X	Other Technician	H620465067432	MI

General Provider Information

NPI Number	:	1801331715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HARRIS

Provider Business Mailing Address
First Line	:	9266 LOUIS
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48239-1732
Country	:	US
Telephone Number	:	313-318-3223
Fax Number	:

Provider Business Practice Location Address
First Line	:	9266 LOUIS
Second Line	:
City	:	REDFORD
State	:	MI
Zip	:	48239-1732
Country	:	US
Telephone Number	:	313-318-3223
Fax Number	:

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

Provider Enumeration Date	:	01/01/2017
Last Update Date	:	01/01/2017

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