Provider Demographics
NPI:1700036357
Name:KELLY EYE CENTER
Entity Type:Organization
Organization Name:KELLY EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-282-1100
Mailing Address - Street 1:10321 LUMLEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8640
Mailing Address - Country:US
Mailing Address - Phone:919-282-1100
Mailing Address - Fax:919-282-1119
Practice Address - Street 1:10321 LUMLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8640
Practice Address - Country:US
Practice Address - Phone:919-282-1100
Practice Address - Fax:919-282-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802107Medicaid