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General NPI Number Information
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NPI Number | 1083749824
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Entity Type | Organization
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Legal Business Name | KELLY'S PRIMARY CARE, INC
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 06/07/2011
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Provider Practice Location Address
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Address Line | 2009 N CONWAY AVE
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City | MISSION
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State | TX
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Zip | 78572-2965
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Country | US
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Telephone | 956-583-0141
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Fax | 956-583-0143
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Provider Business Mailing Address
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Address Line | 2007 N CONWAY AVE
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City | MISSION
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State | TX
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Zip | 78572
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Country | US
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Telephone | 956-583-0141
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Fax | 956-583-0143
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JAYNIE CHAPA
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Credential | RN
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Telephone | 956-583-0141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 006524
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License Number State | TX
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