Provider Demographics
NPI:1609624162
Name:KELLO, EMMEITT III
Entity type:Individual
Prefix:
First Name:EMMEITT
Middle Name:
Last Name:KELLO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61593
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23466-1593
Mailing Address - Country:US
Mailing Address - Phone:757-701-1654
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:757-701-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT69005962343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)