Provider Demographics
NPI:1184898926
Name:KEVIN P RECKLEY OD
Entity type:Organization
Organization Name:KEVIN P RECKLEY OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:RECKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-781-9090
Mailing Address - Street 1:5611 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-3750
Mailing Address - Country:US
Mailing Address - Phone:317-781-9090
Mailing Address - Fax:317-782-3937
Practice Address - Street 1:5611 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3750
Practice Address - Country:US
Practice Address - Phone:317-781-9090
Practice Address - Fax:317-782-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002071332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4118840001Medicare NSC