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General NPI Number Information
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NPI Number | 1508110503
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Entity Type | Organization
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Legal Business Name | KELLY L MCKERAHAN D O A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 10/30/2012
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Last Update Date | 11/13/2012
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Provider Practice Location Address
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Address Line | 25095 JEFFERSON AVE STE 202
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City | MURRIETA
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State | CA
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Zip | 92562-9107
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Country | US
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Telephone | 951-696-9566
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Fax | 951-696-9536
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Provider Business Mailing Address
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Address Line | 25095 JEFFERSON AVE STE 202
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City | MURRIETA
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State | CA
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Zip | 92562-9107
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Country | US
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Telephone | 951-696-9566
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Fax | 951-696-9536
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Authorized Official
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Title or Position | PHYSICIAN
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Name | KELLY LEE MCKERAHAN
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Credential | D.O.
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Telephone | 951-696-9566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 20A6780
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License Number State | CA
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