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General NPI Number Information
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NPI Number | 1982056750
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Entity Type | Individual
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Provider Name | KELLY WILLARD O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/05/2016
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 8084 RIVERS AVE STE 202
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9235
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Country | US
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Telephone | 800-485-9196
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Fax |
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Provider Business Mailing Address
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Address Line | 154 SWEET ALYSSUM DR
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City | LADSON
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State | SC
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Zip | 29456-3898
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Country | US
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Telephone | 773-759-2679
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 2211
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2452
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License Number State | SC
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