Provider Demographics
NPI:1598199853
Name:KELLY, EMMA
Entity type:Organization
Organization Name:KELLY, EMMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-571-2235
Mailing Address - Street 1:509 CALHOUN AVE
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-3614
Mailing Address - Country:US
Mailing Address - Phone:813-571-2235
Mailing Address - Fax:813-571-2235
Practice Address - Street 1:509 CALHOUN AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-3614
Practice Address - Country:US
Practice Address - Phone:813-571-2235
Practice Address - Fax:813-571-2235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905766311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142382700Medicaid