Provider Demographics
NPI:1104436211
Name:MATHIS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 DOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5776
Mailing Address - Country:US
Mailing Address - Phone:307-389-8953
Mailing Address - Fax:
Practice Address - Street 1:617 BROADWAY ST STE C
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6380
Practice Address - Country:US
Practice Address - Phone:307-382-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist