=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598199853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY, EMMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2013
-----------------------------------------------------
Last Update Date | 08/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 CALHOUN AVE
-----------------------------------------------------
City | SEFFNER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33584-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-571-2235
-----------------------------------------------------
Fax | 813-571-2235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 CALHOUN AVE
-----------------------------------------------------
City | SEFFNER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33584-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-571-2235
-----------------------------------------------------
Fax | 813-571-2235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. EMMA LEE KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-571-2235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6905766
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------