Provider Demographics
NPI:1427555812
Name:KELLEY, ARDIS
Entity Type:Individual
Prefix:
First Name:ARDIS
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2469 STATE ROUTE 19 N
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9336
Mailing Address - Country:US
Mailing Address - Phone:585-786-8505
Mailing Address - Fax:585-786-8490
Practice Address - Street 1:6003 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:14480-9753
Practice Address - Country:US
Practice Address - Phone:585-346-2400
Practice Address - Fax:585-346-2413
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005911-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician