Healthcare Provider Details

I. General information

NPI: 1205869500
Provider Name (Legal Business Name): DENNIS WILLIAM KELLINGTON MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MANLEY FIELD HOUSE
SYRACUSE NY
13244-5020
US

IV. Provider business mailing address

MANLEY FIELD HOUSE
SYRACUSE NY
13244-5020
US

V. Phone/Fax

Practice location:
  • Phone: 315-443-4775
  • Fax: 315-443-5057
Mailing address:
  • Phone: 315-443-4775
  • Fax: 315-443-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number001364-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: