Provider Demographics
NPI:1649823014
Name:KELLEY'S OPTICAL
Entity type:Organization
Organization Name:KELLEY'S OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-318-8306
Mailing Address - Street 1:7811 SMOKE RISE RD SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3915
Mailing Address - Country:US
Mailing Address - Phone:256-318-8306
Mailing Address - Fax:
Practice Address - Street 1:11821 S MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-3333
Practice Address - Country:US
Practice Address - Phone:256-318-8306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty