Healthcare Provider Details

I. General information

NPI: 1033701776
Provider Name (Legal Business Name): KELLY MAYO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E HOLLY BLVD
BRANDON SD
57005-1114
US

IV. Provider business mailing address

6705 S CLIFF AVE
SIOUX FALLS SD
57108-8585
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-8800
  • Fax: 605-582-8820
Mailing address:
  • Phone: 605-334-6656
  • Fax: 605-271-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT11035
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: