Basic Information
Provider Information | |||||||||
NPI: | 1821301961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | JASON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 NEW FIDELITY CT | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275292665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9192582714 | ||||||||
FaxNumber: | 4106484878 | ||||||||
Practice Location | |||||||||
Address1: | 300B TEMPLE LAKE DR STE 1 | ||||||||
Address2: |   | ||||||||
City: | COLONIAL HEIGHTS | ||||||||
State: | VA | ||||||||
PostalCode: | 238342973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045249036 | ||||||||
FaxNumber: | 8045249039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2010 | ||||||||
LastUpdateDate: | 05/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305206555 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 192946 | 01 | VA | BCBS (PHYSICAL THERAPY) | OTHER | 1821301961 | 05 | VA |   | MEDICAID | 9631527 | 01 | VA | AETNA | OTHER |