Provider Demographics
NPI:1588812937
Name:KELLY'S FASHION OPTICAL
Entity type:Organization
Organization Name:KELLY'S FASHION OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:I
Authorized Official - Last Name:HERNANDEZ-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:OPTHALMIC DISPENSER
Authorized Official - Phone:718-618-7543
Mailing Address - Street 1:529 E 138TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4925
Mailing Address - Country:US
Mailing Address - Phone:718-618-7443
Mailing Address - Fax:718-618-7545
Practice Address - Street 1:529 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-4925
Practice Address - Country:US
Practice Address - Phone:718-618-7443
Practice Address - Fax:718-618-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FC0800X
NY008692156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty