Healthcare Provider Details

I. General information

NPI: 1215711171
Provider Name (Legal Business Name): KELLIS HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 SOUTH ST
GREENFIELD OH
45123-1432
US

IV. Provider business mailing address

404 SOUTH ST
GREENFIELD OH
45123-1432
US

V. Phone/Fax

Practice location:
  • Phone: 937-403-4051
  • Fax:
Mailing address:
  • Phone: 937-403-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: KARLA L KELLIS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 937-403-4051