Provider Demographics
NPI:1235104233
Name:KELLIE D STENNIS OD PC
Entity Type:Organization
Organization Name:KELLIE D STENNIS OD PC
Other - Org Name:FAMILY EYECARE OF BRIGHTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:STENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-654-7933
Mailing Address - Street 1:193 S 27TH AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2662
Mailing Address - Country:US
Mailing Address - Phone:303-654-7933
Mailing Address - Fax:303-637-9002
Practice Address - Street 1:193 S 27TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2662
Practice Address - Country:US
Practice Address - Phone:303-654-7933
Practice Address - Fax:303-637-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1241650001Medicare NSC
CO315411Medicare PIN
U66123Medicare UPIN