Healthcare Provider Details

I. General information

NPI: 1891969960
Provider Name (Legal Business Name): WILLIAM M. KELLY M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31565 RANCHO PUEBLA RD SUITE 101
TEMECULA CA
92592-4839
US

IV. Provider business mailing address

44489 TOWN CENTER WAY STE. D
PALM DESERT CA
92260-2789
US

V. Phone/Fax

Practice location:
  • Phone: 951-302-2225
  • Fax: 951-302-2210
Mailing address:
  • Phone: 760-776-9777
  • Fax: 760-776-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA34125
License Number StateCA

VIII. Authorized Official

Name: MS. MELONIE STORER
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 951-302-2223