MEDICARE: KELLEY AMADASUN IV

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1629010970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY AMADASUN IV

Provider Business Mailing Address
First Line	:	905 GREEN COVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75232-1639
Country	:	US
Telephone Number	:	214-374-6722
Fax Number	:	214-376-3909

Provider Business Practice Location Address
First Line	:	905 GREEN COVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75232-1639
Country	:	US
Telephone Number	:	214-374-6722
Fax Number	:	214-376-3909

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	07/08/2007

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