Healthcare Provider Details

I. General information

NPI: 1639166317
Provider Name (Legal Business Name): LAWRENCE D KELLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 E STATE ROAD 434 SUITE 1071
LONGWOOD FL
32750-5201
US

IV. Provider business mailing address

587 E STATE ROAD 434 SUITE 1071
LONGWOOD FL
32750-5201
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-8500
  • Fax: 407-767-6999
Mailing address:
  • Phone: 407-767-8500
  • Fax: 407-767-6999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE DELANO KELLEY
Title or Position: OWNER
Credential: M.D.
Phone: 407-767-8500