Provider Demographics
NPI:1386875714
Name:KELLY MEDICAL, INC.
Entity type:Organization
Organization Name:KELLY MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-458-7799
Mailing Address - Street 1:1204 N LAKE PARK BLVD
Mailing Address - Street 2:UNIT F.
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-4163
Mailing Address - Country:US
Mailing Address - Phone:910-458-7799
Mailing Address - Fax:910-458-5325
Practice Address - Street 1:1204 N LAKE PARK BLVD
Practice Address - Street 2:UNIT F.
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-4163
Practice Address - Country:US
Practice Address - Phone:910-458-7799
Practice Address - Fax:910-458-5325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3418849251K00000X
NC01533332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418849Medicaid
NC7705155Medicaid
NC6357280001Medicare NSC