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General NPI Number Information
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NPI Number | 1912570862
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Entity Type | Individual
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Provider Name | BENJAMIN KENNETH KELLY LAT, ATC, ITAT
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Gender | Male
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Dates
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Enumeration Date | 07/19/2021
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Last Update Date | 05/30/2024
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Provider Practice Location Address
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Address Line | 86 PRIDE PKWY
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City | ACCIDENT
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State | MD
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Zip | 21520-2006
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Country | US
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Telephone | 301-746-8668
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Fax |
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Provider Business Mailing Address
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Address Line | 305 DORN AVE
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City | CUMBERLAND
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State | MD
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Zip | 21502-3225
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Country | US
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Telephone | 240-362-3188
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001691
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | A0000671
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License Number State | MD
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