Healthcare Provider Details

I. General information

NPI: 1013455542
Provider Name (Legal Business Name): THOMAS B KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 SEVERIN DR
LA MESA CA
91942-3806
US

IV. Provider business mailing address

5905 SEVERIN DR
LA MESA CA
91942-3806
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-2606
  • Fax: 619-464-0900
Mailing address:
  • Phone: 619-589-2606
  • Fax: 619-464-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: