Physician Compare National (NPI:1679639033)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1679639033
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	7618137738
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20120328000292
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	KELLEY
	Individual professional last name
Provider First Name	LARRY
	Individual professional first name
Provider Middle Name	B
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	SOUTHERN COLLEGE OF OPTOMETRY
	Individual professional's medical school
Graduation Year	1970
	Individual professional's medical school graduation year
Primary Specialty	OPTOMETRY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	1805 COOKS HILL RD
	Group Practice or individual's line 1 address
City	CENTRALIA
	Group Practice or individual's city
State	WA
	Group Practice or individual's state
Zip Code	985319072
	Group Practice or individual's zip code (9 digits when available)
Phone Number	3607364447
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	Y