Healthcare Provider Details

I. General information

NPI: 1750119889
Provider Name (Legal Business Name): KELLY KIRK CCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET ST
LIMA OH
45801-4602
US

IV. Provider business mailing address

355 OAK PARK ST
SUMMERVILLE SC
29486-2088
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-3361
  • Fax:
Mailing address:
  • Phone: 843-270-9456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number000150
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: