Healthcare Provider Details

I. General information

NPI: 1629308564
Provider Name (Legal Business Name): DAVID B. KELLEY, M.D., INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2009
Last Update Date: 12/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 LILLY RD NE STE C
OLYMPIA WA
98506-6954
US

IV. Provider business mailing address

408 LILLY RD NE STE C
OLYMPIA WA
98506-6954
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-5545
  • Fax: 360-456-5854
Mailing address:
  • Phone: 360-456-5545
  • Fax: 360-456-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD00016317
License Number StateWA

VIII. Authorized Official

Name: DR. DAVID B KELLEY
Title or Position: PRESIDENT & CEO
Credential: M.D.
Phone: 360-456-5545