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General NPI Number Information
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NPI Number | 1194240358
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Entity Type | Organization
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Legal Business Name | KELLY KEANE OD PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/09/2017
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Last Update Date | 07/24/2021
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Provider Practice Location Address
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Address Line | 5680 BALBOA AVE
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City | SAN DIEGO
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State | CA
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Zip | 92111-2706
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Country | US
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Telephone | 858-278-2837
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Fax |
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Provider Business Mailing Address
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Address Line | 4203 GENESEE AVE SUITE 103 #436
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City | SAN DIEGO
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State | CA
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Zip | 92117-5071
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Country | US
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Telephone | 973-557-5521
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. KELLY KEANE
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Credential | OD
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Telephone | 973-557-5521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 15197
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License Number State | CA
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