Healthcare Provider Details

I. General information

NPI: 1740419068
Provider Name (Legal Business Name): KELLY VEIHL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 STATE ST #5
QUINCY IL
62301-4951
US

IV. Provider business mailing address

804 STATE STREET #5
QUINCY IL
62301
US

V. Phone/Fax

Practice location:
  • Phone: 217-224-1750
  • Fax: 217-224-0403
Mailing address:
  • Phone: 217-224-1750
  • Fax: 217-224-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-005031
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: