Provider Demographics
NPI:1578761979
Name:RICE-KELLY, DENICE ANN (OD)
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:ANN
Last Name:RICE-KELLY
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 1:4970 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3552
Mailing Address - Country:US
Mailing Address - Phone:708-867-7838
Mailing Address - Fax:708-867-5869
Practice Address - Street 1:4970 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:HARWOOD HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60706-3552
Practice Address - Country:US
Practice Address - Phone:708-867-7838
Practice Address - Fax:708-867-5869
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL521020OtherMEDICARE PROVIDER GROUP #
ILU60758Medicare UPIN
ILL66988Medicare PIN