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General NPI Number Information
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NPI Number | 1992036883
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Entity Type | Organization
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Legal Business Name | KAY KELLY TRADITIONAL CHINESE MEDICINE, INC.
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Dates
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Enumeration Date | 01/17/2010
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Last Update Date | 01/17/2010
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Provider Practice Location Address
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Address Line | 12220 45TH AVE N
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City | PLYMOUTH
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State | MN
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Zip | 55442-2443
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Country | US
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Telephone | 763-213-9989
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Fax |
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Provider Business Mailing Address
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Address Line | 12220 45TH AVE N
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City | PLYMOUTH
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State | MN
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Zip | 55442-2443
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Country | US
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Telephone | 763-213-9989
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KAY DEVINE KELLY
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Credential | L.AC.
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Telephone | 763-213-9989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1015
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License Number State | MN
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