1730515933 NPI number — KELLY HOUSE OPERATIONS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730515933 NPI number — KELLY HOUSE OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY HOUSE OPERATIONS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730515933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3715 SW 29TH ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66614-2164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-272-1535
Provider Business Mailing Address Fax Number:
785-272-1480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 SW FAIRMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66604-3699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-271-9594
Provider Business Practice Location Address Fax Number:
785-271-6638
Provider Enumeration Date:
09/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TRYON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
785-272-1535

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  N089034 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100274660A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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