1063558070 NPI number — KELLY AND VELAZQUEZ EYE CENTER PC

Table of content: (NPI 1063558070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063558070 NPI number — KELLY AND VELAZQUEZ EYE CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY AND VELAZQUEZ EYE CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063558070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01069-1215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-283-3511
Provider Business Mailing Address Fax Number:
413-283-5396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
362 SEWALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDLOW
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01056-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-589-7308
Provider Business Practice Location Address Fax Number:
413-547-8933
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
413-284-4481

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  41270 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 735819 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: MA1270 . This is a "EYEMED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0218430001 . This is a "DME MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 39707 . This is a "DAVIS VISION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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