Healthcare Provider Details

I. General information

NPI: 1346499928
Provider Name (Legal Business Name): MIKE KELO PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12212 BRANDERS CREEK DR
CHESTER VA
23831-1626
US

IV. Provider business mailing address

12212 BRANDERS CREEK DR
CHESTER VA
23831-1626
US

V. Phone/Fax

Practice location:
  • Phone: 804-425-4545
  • Fax: 804-778-4522
Mailing address:
  • Phone: 804-425-4545
  • Fax: 804-425-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305002847
License Number StateVA

VIII. Authorized Official

Name: MR. MICHAEL JOHN KELO
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 804-366-8518