Healthcare Provider Details

I. General information

NPI: 1962427666
Provider Name (Legal Business Name): J & S KELLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S MAIN ST
KEWANEE IL
61443-2861
US

IV. Provider business mailing address

730 E KIMBERLY RD
DAVENPORT IA
52807-1621
US

V. Phone/Fax

Practice location:
  • Phone: 309-856-5870
  • Fax: 309-854-0728
Mailing address:
  • Phone: 563-386-1553
  • Fax: 563-391-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203.000827
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number1254070004
License Number StateIL

VIII. Authorized Official

Name: MR. WILLIAM M KELLENBERGER
Title or Position: OWNER
Credential:
Phone: 563-386-1553