Healthcare Provider Details

I. General information

NPI: 1437202819
Provider Name (Legal Business Name): TERRI KELLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 KATHERINE AVE
JOPLIN MO
64801-5888
US

IV. Provider business mailing address

PO BOX 2966 1801 KATHERINE ST
JOPLIN MO
64803-2966
US

V. Phone/Fax

Practice location:
  • Phone: 417-626-9729
  • Fax: 471-206-4113
Mailing address:
  • Phone: 417-626-9729
  • Fax: 471-206-4113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number309
License Number StateMO

VIII. Authorized Official

Name: MICHAEL KELLEY
Title or Position: PRESIDENT
Credential:
Phone: 417-626-9729