Healthcare Provider Details

I. General information

NPI: 1164044111
Provider Name (Legal Business Name): KELSEY SCHULTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20046 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5304
US

IV. Provider business mailing address

20046 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5304
US

V. Phone/Fax

Practice location:
  • Phone: 239-719-0009
  • Fax:
Mailing address:
  • Phone: 510-881-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34616
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: