Healthcare Provider Details

I. General information

NPI: 1740713569
Provider Name (Legal Business Name): KELLY KING CLEARY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2017
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4159 MILL ST NE
COVINGTON GA
30014-2546
US

IV. Provider business mailing address

4159 MILL ST NE
COVINGTON GA
30014-2546
US

V. Phone/Fax

Practice location:
  • Phone: 770-786-1234
  • Fax: 770-385-0813
Mailing address:
  • Phone: 770-786-1234
  • Fax: 770-385-0813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003007
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: