Healthcare Provider Details

I. General information

NPI: 1104215300
Provider Name (Legal Business Name): JAMES KELLY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8937 WOODMAN WAY
SACRAMENTO CA
95826-2140
US

IV. Provider business mailing address

8937 WOODMAN WAY
SACRAMENTO CA
95826-2140
US

V. Phone/Fax

Practice location:
  • Phone: 916-715-9479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberAT 9303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: