MEDICARE: IMKELLEYLLC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1164267167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMKELLEYLLC

Provider Business Mailing Address
First Line	:	255 N WASHINGTON ST APT 237
Second Line	:
City	:	ROCKVILLE
State	:	MD
Zip	:	20850-1760
Country	:	US
Telephone Number	:	240-706-7824
Fax Number	:

Provider Business Practice Location Address
First Line	:	6250 COLUMBIA CROSSING CIR # 4
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-8010
Country	:	US
Telephone Number	:	240-706-7824
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IRENE MARIE WATKINS
Credential	:	HAIR LOSS SPECIALIST
Telephone Number	:	240-706-7824

Provider Enumeration Date	:	07/01/2024
Last Update Date	:	07/01/2024

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