Provider Demographics
NPI:1639264427
Name:KERRY A OKELBERRY O D P C
Entity Type:Organization
Organization Name:KERRY A OKELBERRY O D P C
Other - Org Name:REDWOOD VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:OKELBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-268-0866
Mailing Address - Street 1:6705 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-2402
Mailing Address - Country:US
Mailing Address - Phone:801-268-0866
Mailing Address - Fax:801-268-2092
Practice Address - Street 1:6705 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-2402
Practice Address - Country:US
Practice Address - Phone:801-268-0866
Practice Address - Fax:801-268-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1125139934332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528904440008Medicaid
UTDR3610OtherRETIRED RAILROAD MEDICARE
UT000009932Medicare PIN
UT000065425Medicare PIN
UTDR3610OtherRETIRED RAILROAD MEDICARE
UTT78186Medicare UPIN