Healthcare Provider Details

I. General information

NPI: 1215955141
Provider Name (Legal Business Name): KELLY LAO OD APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MERIDIAN AVE STE 1
SAN JOSE CA
95126
US

IV. Provider business mailing address

240 MERIDIAN AVE STE 1
SAN JOSE CA
95126
US

V. Phone/Fax

Practice location:
  • Phone: 408-293-7576
  • Fax: 408-293-7579
Mailing address:
  • Phone: 408-293-7576
  • Fax: 408-293-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10646T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLY LAO SENG
Title or Position: PRESIDENT
Credential: OD
Phone: 408-293-7576