Healthcare Provider Details

I. General information

NPI: 1205256187
Provider Name (Legal Business Name): JUSTIN KELLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 FREEDOM BLVD STE 100
FLORENCE SC
29505-6074
US

IV. Provider business mailing address

510 ROSEWOOD DR
FLORENCE SC
29501-5456
US

V. Phone/Fax

Practice location:
  • Phone: 843-413-6835
  • Fax: 843-674-6312
Mailing address:
  • Phone: 334-399-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number34.014089
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34.014089
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number97318
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: