Provider Demographics
NPI:1306964713
Name:KELLEY, RODGER (BA)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-4813
Mailing Address - Country:US
Mailing Address - Phone:323-334-6347
Mailing Address - Fax:
Practice Address - Street 1:3221 N ALAMEDA ST
Practice Address - Street 2:SUITE G
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-1433
Practice Address - Country:US
Practice Address - Phone:310-604-7751
Practice Address - Fax:310-537-9753
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner