Healthcare Provider Details

I. General information

NPI: 1376744912
Provider Name (Legal Business Name): JOHN D KELLEY LPO, CFO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W SHORE DR SUITE 400D
RICHARDSON TX
75080-4054
US

IV. Provider business mailing address

1110 W SHORE DR SUITE 400D
RICHARDSON TX
75080-4054
US

V. Phone/Fax

Practice location:
  • Phone: 972-470-0300
  • Fax: 972-470-0301
Mailing address:
  • Phone: 972-470-0300
  • Fax: 972-470-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1245
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number1245
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: