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General NPI Number Information
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NPI Number | 1780976647
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Entity Type | Organization
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Legal Business Name | BELOIT FAMILY EYE CARE S.C.
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Dates
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Enumeration Date | 05/11/2011
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Last Update Date | 08/17/2011
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Provider Practice Location Address
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Address Line | 540 E GRAND AVE
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City | BELOIT
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State | WI
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Zip | 53511-6314
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Country | US
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Telephone | 608-365-8575
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Fax | 608-362-2655
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Provider Business Mailing Address
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Address Line | 540 E GRAND AVE
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City | BELOIT
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State | WI
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Zip | 53511-6314
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Country | US
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Telephone | 608-365-8575
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Fax | 608-362-2655
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Authorized Official
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Title or Position | MANAGER
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Name | DR. DOUGLAS EDWARD KELLEY
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Credential | OD
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Telephone | 608-365-8575
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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 | 3136-035
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License Number State | WI
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