Healthcare Provider Details

I. General information

NPI: 1639615032
Provider Name (Legal Business Name): TIFFANY KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N PERRIS BLVD
PERRIS CA
92571
US

IV. Provider business mailing address

555 N PERRIS BLVD
PERRIS CA
92571-2811
US

V. Phone/Fax

Practice location:
  • Phone: 951-436-5366
  • Fax:
Mailing address:
  • Phone: 951-436-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: