Provider Demographics
NPI:1659686335
Name:KELLY M RILEY INC
Entity type:Organization
Organization Name:KELLY M RILEY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:806-637-3937
Mailing Address - Street 1:801 E TAHOKA RD
Mailing Address - Street 2:
Mailing Address - City:BROWNFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:79316-3635
Mailing Address - Country:US
Mailing Address - Phone:806-637-3937
Mailing Address - Fax:806-637-3950
Practice Address - Street 1:801 E TAHOKA RD
Practice Address - Street 2:
Practice Address - City:BROWNFIELD
Practice Address - State:TX
Practice Address - Zip Code:79316-3635
Practice Address - Country:US
Practice Address - Phone:806-637-3937
Practice Address - Fax:806-637-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6923TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2163347-01Medicaid