Provider Demographics
NPI:1750808804
Name:HANKS, KELLY A (OTC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:HANKS
Suffix:
Gender:F
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24331 EL TORO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-3116
Mailing Address - Country:US
Mailing Address - Phone:949-586-3200
Mailing Address - Fax:949-540-7154
Practice Address - Street 1:24331 EL TORO RD STE 200
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-3116
Practice Address - Country:US
Practice Address - Phone:949-586-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist