Basic Information
| Provider Information | |||||||||
| NPI: | 1144486903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELLEY SPORTS MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40949 WINCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925916031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512966676 | ||||||||
| FaxNumber: | 9512966675 | ||||||||
| Practice Location | |||||||||
| Address1: | 40949 WINCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925916031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512966676 | ||||||||
| FaxNumber: | 9512966675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | KELLEY | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9512966676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A78913 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.