Individual
MR. KELLY JOE THOMAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BS MT(ASCP) CLS(NCA)
Contact information
Practice address
3200 CANYON LAKE DR, RAPID CITY, SD 57702-8114
(605) 355-2229
(305) 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
204742
—
246QM0706X
Medical Technologist
206256
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0140070
—
SD
01
—
5549050
MEDICAID
SD
Enumeration date
02/10/2010
Last updated
02/10/2010
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