MEDICARE: DEQUITA 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1972983856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEQUITA KELLY

Provider Business Mailing Address
First Line	:	2108 RODNEY LN
Second Line	:
City	:	BALCH SPRINGS
State	:	TX
Zip	:	75180-1369
Country	:	US
Telephone Number	:	214-290-4650
Fax Number	:

Provider Business Practice Location Address
First Line	:	2108 RODNEY LN
Second Line	:
City	:	BALCH SPRINGS
State	:	TX
Zip	:	75180-1369
Country	:	US
Telephone Number	:	214-290-4650
Fax Number	:

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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Directions to “ DEQUITA KELLY ” Practice Location

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