Provider Demographics
NPI:1639350911
Name:SANDRA CAMMILLERI KELLETT OD, FAAO, PC
Entity Type:Organization
Organization Name:SANDRA CAMMILLERI KELLETT OD, FAAO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-962-8111
Mailing Address - Street 1:3630 HILL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:JEFFERSON VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10535-1505
Mailing Address - Country:US
Mailing Address - Phone:914-962-8111
Mailing Address - Fax:914-962-8160
Practice Address - Street 1:3630 HILL BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:JEFFERSON VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10535-1505
Practice Address - Country:US
Practice Address - Phone:914-962-8111
Practice Address - Fax:914-962-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005605-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4242180001Medicare NSC