Healthcare Provider Details

I. General information

NPI: 1013637925
Provider Name (Legal Business Name): MR. CONN OSCAR KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 MIDWAY DRIVE
KENT OH
44242-0001
US

IV. Provider business mailing address

2914 GREEN RD
SHAKER HEIGHTS OH
44122-3052
US

V. Phone/Fax

Practice location:
  • Phone: 802-598-1282
  • Fax:
Mailing address:
  • Phone: 802-598-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: