Provider Demographics
NPI:1154489391
Name:EHLE, KELLY (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EHLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:EHLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:7302 SILVER RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7668
Mailing Address - Country:US
Mailing Address - Phone:616-874-3318
Mailing Address - Fax:
Practice Address - Street 1:2974 28TH ST SE
Practice Address - Street 2:STE A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1664
Practice Address - Country:US
Practice Address - Phone:616-949-2120
Practice Address - Fax:616-949-9015
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930114Medicare PIN