Basic Information
| Provider Information | |||||||||
| NPI: | 1306285564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | BRYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307593251 | ||||||||
| Practice Location | |||||||||
| Address1: | 3218 DAUGHERTY DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479093997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654776464 | ||||||||
| FaxNumber: | 7654776262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05011222A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.