Basic Information
| Provider Information | |||||||||
| NPI: | 1124382684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5316 TRAIL LAKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761331931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 6202 IOLA AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794242728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003404098 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1168068 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID | 207164901 | 05 | TX | MEDICAID |