MEDICARE: MR. MICHAEL JASON KELLEY

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	2471C3402X	Radiography Radiologic Technologist

General Provider Information

NPI Number	:	1912174731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL JASON KELLEY

Provider Business Mailing Address
First Line	:	1209 HEATHERVIEW DR
Second Line	:
City	:	OAK PARK
State	:	CA
Zip	:	91377-3914
Country	:	US
Telephone Number	:	818-879-8037
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 HEATHERVIEW DR
Second Line	:
City	:	OAK PARK
State	:	CA
Zip	:	91377-3914
Country	:	US
Telephone Number	:	818-879-8037
Fax Number	:

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

Provider Enumeration Date	:	05/12/2008
Last Update Date	:	07/03/2008

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