Healthcare Provider Details

I. General information

NPI: 1255663670
Provider Name (Legal Business Name): KELLY JOE THOMAS BS MT(ASCP) CLS(NCA)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2229
  • Fax: 305-355-2514
Mailing address:
  • Phone: 605-355-2229
  • Fax: 605-355-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number204742
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number206256
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: