Provider Demographics
NPI:1316942915
Name:J&S KELLY LLC
Entity type:Organization
Organization Name:J&S KELLY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-386-1553
Mailing Address - Street 1:730 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1621
Mailing Address - Country:US
Mailing Address - Phone:563-386-1553
Mailing Address - Fax:563-449-5450
Practice Address - Street 1:730 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1621
Practice Address - Country:US
Practice Address - Phone:563-386-1553
Practice Address - Fax:563-449-5450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAW00200148332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0185272Medicaid
IA0185272Medicaid