MEDICARE: COLUMBIA RIVER EYE CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1528247988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA RIVER EYE CLINIC LLC

Provider Business Mailing Address
First Line	:	405 E 7TH ST
Second Line	:
City	:	THE DALLES
State	:	OR
Zip	:	97058-2607
Country	:	US
Telephone Number	:	541-298-5144
Fax Number	:	541-298-5224

Provider Business Practice Location Address
First Line	:	405 E 7TH ST
Second Line	:
City	:	THE DALLES
State	:	OR
Zip	:	97058-2607
Country	:	US
Telephone Number	:	541-298-5144
Fax Number	:	541-298-5224

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL JOSEPH KELLY
Credential	:	MD
Telephone Number	:	541-298-5144

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	05/07/2008

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