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NPI Code Detail

MEDICARE: KENJACK MEDICAL LLC

MEDICARE: KENJACK MEDICAL LLC
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
1207Q00000XFamily Medicine Physician0102036923VA

General Provider Information

NPI Number : 1528423555
Entity Type Code : Organization
Provider Name (Legal Business Name) : KENJACK MEDICAL LLC
Provider Business Mailing Address
First Line : 951 W 21ST ST
Second Line :
City : NORFOLK
State : VA
Zip : 23517-1534
Country : US
Telephone Number : 757-274-4452
Fax Number : 757-531-7723
Provider Business Practice Location Address
First Line : 951 W 21ST ST
Second Line :
City : NORFOLK
State : VA
Zip : 23517-1534
Country : US
Telephone Number : 757-274-4452
Fax Number : 757-531-7723
Authorized Official
Title or Position : PRESIDENT
Name : DR. GARRETT M KELLY
Credential : D.O.
Telephone Number : 757-274-4452
Provider Enumeration Date : 12/17/2015
Last Update Date : 05/01/2017

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Directions to “KENJACK MEDICAL LLC ” Practice Location

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