Provider Demographics
NPI:1205511086
Name:KELLEY, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 ROUTE 130 NORTH
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-2907
Mailing Address - Country:US
Mailing Address - Phone:609-443-6484
Mailing Address - Fax:609-443-6492
Practice Address - Street 1:839 ROUTE 130 NORTH
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:NJ
Practice Address - Zip Code:08520
Practice Address - Country:US
Practice Address - Phone:609-443-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
31TD00104400156FX1800X
NJ31TD00104400156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician