Provider Demographics
NPI:1811201692
Name:MCCARTNEY, KELLI MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:MARIE
Last Name:MCCARTNEY
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 1:107 HISTORY LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-7850
Mailing Address - Country:US
Mailing Address - Phone:843-419-8600
Mailing Address - Fax:
Practice Address - Street 1:2010 PAXVILLE HWY
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-6434
Practice Address - Country:US
Practice Address - Phone:803-408-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1850152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4313891Medicare PIN