Provider Demographics
NPI:1164267167
Name:IMKELLEYLLC
Entity type:Organization
Organization Name:IMKELLEYLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:240-706-7824
Mailing Address - Street 1:255 N WASHINGTON ST APT 237
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1760
Mailing Address - Country:US
Mailing Address - Phone:240-706-7824
Mailing Address - Fax:
Practice Address - Street 1:6250 COLUMBIA CROSSING CIR # 4
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-8010
Practice Address - Country:US
Practice Address - Phone:240-706-7824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies