Individual
MR. DAN DALE KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
120 BIRCH ST, SHADY COVE, OR 97539
(541) 878-2429
Mailing address
PO BOX 1516, SHADY COVE, OR 97539
(541) 878-2429
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
—
—
372500000X
Chore Provider
—
—
372600000X
Adult Companion
Primary
—
—
Other
Enumeration date
05/17/2010
Last updated
05/17/2010
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