| Kenjack Medical Llc | |
|
951 W 21st St Norfolk VA 23517-1534 | |
| (757) 274-4452 | |
| (757) 531-7723 |
| Full Name | Kenjack Medical Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 951 W 21st St, Norfolk, Virginia |
| Authorized Official Name and Position | Garrett M Kelly (PRESIDENT) |
| Authorized Official Contact | 7572744452 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Kenjack Medical Llc 951 W 21st St Norfolk VA 23517-1534 Ph: (757) 274-4452 | Kenjack Medical Llc 951 W 21st St Norfolk VA 23517-1534 Ph: (757) 274-4452 |
| NPI Number | 1528423555 |
|---|---|
| Provider Enumeration Date | 12/17/2015 |
| Last Update Date | 05/01/2017 |
| Medicare PECOS PAC ID | 7810293594 |
|---|---|
| Medicare Enrollment ID | O20160307000287 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528423555 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 0102036923 (Virginia) | Primary |
| Provider Name | Garrett M Kelly |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1407820939 PECOS PAC ID: 1951200419 Enrollment ID: I20040103000002 |
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