Provider Demographics
NPI:1497004931
Name:LE, KELLY H (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:H
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:11941 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-4502
Practice Address - Country:US
Practice Address - Phone:314-884-2380
Practice Address - Fax:314-884-2381
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2012027367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist