Provider Demographics
NPI:1043693468
Name:KELLY, MICHAEL R
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KELLY
Suffix:
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 1:458 TALCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4052
Mailing Address - Country:US
Mailing Address - Phone:860-875-6156
Mailing Address - Fax:860-872-3828
Practice Address - Street 1:458 TALCOTTVILLE RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4052
Practice Address - Country:US
Practice Address - Phone:860-875-6156
Practice Address - Fax:860-872-3828
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000733156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician