Healthcare Provider Details

I. General information

NPI: 1982515045
Provider Name (Legal Business Name): KYLIE QUEEN LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 FURR ST
SOUTH HILL VA
23970-9500
US

IV. Provider business mailing address

315 FURR ST
SOUTH HILL VA
23970-9500
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-2777
  • Fax: 434-447-2908
Mailing address:
  • Phone: 434-447-2777
  • Fax: 434-447-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101004765
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: