Provider Demographics
NPI:1184116097
Name:RICCOBONO, KELLEN RUTH (OD)
Entity type:Individual
Prefix:
First Name:KELLEN
Middle Name:RUTH
Last Name:RICCOBONO
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 1:2430 S IH 35 STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5912
Mailing Address - Country:US
Mailing Address - Phone:512-353-1300
Mailing Address - Fax:512-353-5135
Practice Address - Street 1:2430 S IH 35 STE 106
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5912
Practice Address - Country:US
Practice Address - Phone:512-353-1300
Practice Address - Fax:512-353-5135
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9491TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist