Healthcare Provider Details

I. General information

NPI: 1073207064
Provider Name (Legal Business Name): KC KELLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 MEMORIAL AVE STE 10
LYNCHBURG VA
24501-2652
US

IV. Provider business mailing address

16890 FOREST RD
FOREST VA
24551-4059
US

V. Phone/Fax

Practice location:
  • Phone: 143-420-0615
  • Fax:
Mailing address:
  • Phone: 434-200-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116037899
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0102210148
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116037899
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: