Provider Demographics
NPI:1184171423
Name:SYKES, KELSEY LONG (OD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LONG
Last Name:SYKES
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 1:1425 W MAIN ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3283
Mailing Address - Country:US
Mailing Address - Phone:406-586-2173
Mailing Address - Fax:406-586-3603
Practice Address - Street 1:1425 W MAIN ST UNIT B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3283
Practice Address - Country:US
Practice Address - Phone:406-586-2173
Practice Address - Fax:406-586-3603
Is Sole Proprietor?:No
Enumeration Date:2016-09-03
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS992152W00000X
MT3673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist