=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811662414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAVEAR KELLY LDO, ABOC, NCLEC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3277 EMBRY DOWNS CT
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-333-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3277 EMBRY DOWNS CT
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30340-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-333-9500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FC0800X
-----------------------------------------------------
Taxonomy Name | Contact Lens Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FC0801X
-----------------------------------------------------
Taxonomy Name | Contact Lens Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | LDO002174
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------