Healthcare Provider Details

I. General information

NPI: 1144814138
Provider Name (Legal Business Name): KELLAR SURGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 GLEN WILLOW CT
GREER SC
29650-2568
US

IV. Provider business mailing address

14 GLEN WILLOW CT
GREER SC
29650-2568
US

V. Phone/Fax

Practice location:
  • Phone: 954-529-6843
  • Fax:
Mailing address:
  • Phone: 954-529-6843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. GABRIELLE MONTEVERGINE KELLAR
Title or Position: OWNER
Credential: CSFA
Phone: 954-529-6843