Healthcare Provider Details

I. General information

NPI: 1104748169
Provider Name (Legal Business Name): KELLY OPTOMETRY, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BASS PRO BLVD
DENHAM SPRINGS LA
70726-5570
US

IV. Provider business mailing address

1 VERMONT DR
NEW HYDE PARK NY
11042-1128
US

V. Phone/Fax

Practice location:
  • Phone: 225-665-2887
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN L CHRISTOPHER-BRAND
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 703-314-8795