Healthcare Provider Details

I. General information

NPI: 1053242073
Provider Name (Legal Business Name): KELTON OGRADY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 S SIGNAL BUTTE RD
MESA AZ
85209-2602
US

IV. Provider business mailing address

PO BOX 1373
CAMP VERDE AZ
86322-1373
US

V. Phone/Fax

Practice location:
  • Phone: 480-272-7797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: