Provider Demographics
NPI:1063509735
Name:NEELY, KIM (LO)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:
Last Name:NEELY
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1939
Mailing Address - Country:US
Mailing Address - Phone:860-928-6321
Mailing Address - Fax:860-928-2239
Practice Address - Street 1:5 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1939
Practice Address - Country:US
Practice Address - Phone:860-928-6321
Practice Address - Fax:860-928-2239
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT812156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0821000001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER