1295718161 NPI number — WILLIAM M. KELLY M.D., INC.

Table of content: (NPI 1295718161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295718161 NPI number — WILLIAM M. KELLY M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM M. KELLY M.D., INC.
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:
OPEN MRI OF LOMA LINDA
Provider Other Organization Name Type Code:
3
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:
1295718161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44489 TOWN CENTER WAY
Provider Second Line Business Mailing Address:
STE. D
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-2789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-776-9777
Provider Business Mailing Address Fax Number:
760-776-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11360 MOUNTAIN VIEW AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-3861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-478-3300
Provider Business Practice Location Address Fax Number:
909-478-3900
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STORER
Authorized Official First Name:
MELONIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING ADMINISTRATOR
Authorized Official Telephone Number:
951-302-2223

Provider Taxonomy Codes

  • Taxonomy code: 2085D0003X , with the licence number:  A34125 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: A34125 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00A341251 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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