Provider Demographics
NPI:1437494572
Name:KELLI L. PARKS, OD, LLC
Entity Type:Organization
Organization Name:KELLI L. PARKS, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-585-8830
Mailing Address - Street 1:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32588-0874
Mailing Address - Country:US
Mailing Address - Phone:850-585-8830
Mailing Address - Fax:
Practice Address - Street 1:740 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3002
Practice Address - Country:US
Practice Address - Phone:850-585-8830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty