Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003239112 |
---|---|
Provider Name | Darris Kelly |
First Address | Pahrump, NV 89060-4532 |
Second Address | Pahrump, NV 89060-4532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2014 |
Last Update Date | 24/01/2014 |