MEDICARE: MARK J KELLY MT, AP, BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	98554	CA

General Provider Information

NPI Number	:	1124901020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK J KELLY MT, AP, BA

Provider Business Mailing Address
First Line	:	255 NEWPORT AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-5922
Country	:	US
Telephone Number	:	562-619-0327
Fax Number	:

Provider Business Practice Location Address
First Line	:	3490 LINDEN AVE STE 3
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-4559
Country	:	US
Telephone Number	:	323-229-2930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2025
Last Update Date	:	07/28/2025

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