Provider Demographics
NPI:1558353938
Name:KELLEY, CAROL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 ORACLE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3764
Mailing Address - Country:US
Mailing Address - Phone:719-487-1511
Mailing Address - Fax:719-487-9480
Practice Address - Street 1:12265 ORACLE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3764
Practice Address - Country:US
Practice Address - Phone:719-487-1511
Practice Address - Fax:719-487-9480
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2023-03-07
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CO1632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1632OtherLICENSE
CO1632OtherLICENSE
CO1632OtherLICENSE