MEDICARE: NICHOLAS DEAN KELLAR

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	390200000X	Student in an Organized Health Care Education/Training Program		CO

General Provider Information

NPI Number	:	1306588595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS DEAN KELLAR

Provider Business Mailing Address
First Line	:	870 DEXTER ST APT 206
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-4141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	361 CENTENNIAL PKWY STE 120
Second Line	:
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-1255
Country	:	US
Telephone Number	:	303-465-2323
Fax Number	:

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

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	11/03/2025

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Directions to “ NICHOLAS DEAN KELLAR ” Practice Location

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