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General NPI Number Information
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NPI Number | 1902685449
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Entity Type | Individual
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Provider Name | NICHOLAS CAMERON KELLEY PT DPT
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Gender | Male
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Dates
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Enumeration Date | 09/25/2023
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 126 AVOCADO AVE STE 107
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City | PERRIS
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State | CA
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Zip | 92571-2605
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Country | US
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Telephone | 951-564-3080
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Fax | 951-564-3081
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Provider Business Mailing Address
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Address Line | 24821 EVENING SHADOW CT
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City | MORENO VALLEY
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State | CA
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Zip | 92557-4207
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Country | US
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Telephone | 951-295-0804
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 304937
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License Number State | CA
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