Provider Demographics
NPI:1376228742
Name:KELLY, CHARLES ROBERT
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
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 1:979 ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-2712
Mailing Address - Country:US
Mailing Address - Phone:732-545-0435
Mailing Address - Fax:
Practice Address - Street 1:WALMART VISION 979 ROUTE 1 SOUTH
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1902
Practice Address - Country:US
Practice Address - Phone:732-545-0435
Practice Address - Fax:732-545-0629
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD3694156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician