MEDICARE: MR. KELLY SIMEON

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	172A00000X	Driver	S550500732920	FL

General Provider Information

NPI Number	:	1508482456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY SIMEON

Provider Business Mailing Address
First Line	:	PO BOX 5941
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33083-5941
Country	:	US
Telephone Number	:	954-256-3673
Fax Number	:	800-390-1648

Provider Business Practice Location Address
First Line	:	360 SE 12TH AVE APT 1
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-4449
Country	:	US
Telephone Number	:	954-256-3673
Fax Number	:	800-390-1648

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

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	06/17/2020

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Directions to “ MR. KELLY SIMEON ” Practice Location

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