Individual
KELLY R WILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BS MLS (ASCP)
Contact information
Practice address
3200 CANYON LAKE DR, RAPID CITY, SD 57702-8114
(605) 355-2229
(605) 355-2514
Mailing address
3200 CANYON LAKE DR, RAPID CITY, SD 57702-8114
(605) 355-2229
(605) 355-2514
Taxonomy
Speciality
Code
Description
License number
State
246QM0706X
Medical Technologist
Primary
25324986
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0140070
—
SD
01
—
5549050
MEDICAID
SD
Enumeration date
10/19/2010
Last updated
10/19/2010
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