Healthcare Provider Details

I. General information

NPI: 1356170054
Provider Name (Legal Business Name): ADAM EDWARD KELLOGG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 E DEL MAR BLVD
PASADENA CA
91107-4375
US

IV. Provider business mailing address

626 DORNIE ST
GLENDORA CA
91741-3208
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-9901
  • Fax:
Mailing address:
  • Phone: 562-599-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95316977
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: