Healthcare Provider Details

I. General information

NPI: 1568952729
Provider Name (Legal Business Name): KELVIN SELLERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 SEWARD
DETRIOT MI
48202
US

IV. Provider business mailing address

832 SEWARD ST
DETROIT MI
48202-2305
US

V. Phone/Fax

Practice location:
  • Phone: 313-579-5172
  • Fax:
Mailing address:
  • Phone: 313-579-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501006579
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: