Kelly Medical, Inc.

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

License

01533 Issued in NC

Legal business name

KELLY MEDICAL, INC.

Practice address

1204 N Lake Park Blvd
Unit F.
Carolina Beach, NC 28428-4163

Phone

(910) 458-7799

Fax

(910) 458-5325

NPI assigned

Aug 3, 2009

Last updated

Nov 4, 2010By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Jack Steven Kelly

Title

Owner

Phone

(910) 458-7799

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in NC

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1249257600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1288828800000",
    "number": "1386875714",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1204 N LAKE PARK BLVD",
            "address_2": "UNIT F.",
            "city": "CAROLINA BEACH",
            "state": "NC",
            "postal_code": "284284163",
            "telephone_number": "910-458-7799",
            "fax_number": "910-458-5325"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1204 N LAKE PARK BLVD",
            "address_2": "UNIT F.",
            "city": "CAROLINA BEACH",
            "state": "NC",
            "postal_code": "284284163",
            "telephone_number": "910-458-7799",
            "fax_number": "910-458-5325"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KELLY MEDICAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-03",
        "last_updated": "2010-11-04",
        "status": "A",
        "authorized_official_last_name": "KELLY",
        "authorized_official_first_name": "JACK",
        "authorized_official_middle_name": "STEVEN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "910-458-7799",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "NC",
            "license": "3418849",
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NC",
            "license": "01533",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7705155",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3418849",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Durable Medical Equipment & Medical Supplies in Carolina Beach, NC
• Providers in Carolina Beach, NC by specialty
• Durable Medical Equipment & Medical Supplies in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.