Provider Demographics
NPI:1962427666
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:OWNER
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:563-391-7702
Practice Address - Street 1:229 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2861
Practice Address - Country:US
Practice Address - Phone:309-856-5870
Practice Address - Fax:309-854-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000827332B00000X
332BX2000X
IL1254070004332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002 1Medicaid
IL=========002 1Medicaid