MEDICARE: KAYLIN KELLY

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	225X00000X	Occupational Therapist	26331	CA

General Provider Information

NPI Number	:	1790502383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLIN KELLY

Provider Business Mailing Address
First Line	:	2262 FOUNTAIN WAY W
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2444
Country	:	US
Telephone Number	:	856-723-0632
Fax Number	:

Provider Business Practice Location Address
First Line	:	5648 GOTHAM ST
Second Line	:
City	:	BELL GARDENS
State	:	CA
Zip	:	90201-5413
Country	:	US
Telephone Number	:	562-927-2641
Fax Number	:

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

Provider Enumeration Date	:	09/24/2024
Last Update Date	:	09/24/2024

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