Provider Demographics
NPI:1447879101
Name:KELLEY HEALTH HOSPICE
Entity type:Organization
Organization Name:KELLEY HEALTH HOSPICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-471-6212
Mailing Address - Street 1:903 11TH ST NE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-8821
Mailing Address - Country:US
Mailing Address - Phone:205-471-6212
Mailing Address - Fax:205-387-1912
Practice Address - Street 1:453 19TH ST W
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5349
Practice Address - Country:US
Practice Address - Phone:205-387-2300
Practice Address - Fax:205-387-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1663EMedicaid