1639350911 NPI number — SANDRA CAMMILLERI KELLETT OD, FAAO, PC

Table of content: (NPI 1639350911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639350911 NPI number — SANDRA CAMMILLERI KELLETT OD, FAAO, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDRA CAMMILLERI KELLETT OD, FAAO, 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:
1639350911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3630 HILL BLVD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
JEFFERSON VALLEY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10535-1505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-962-8111
Provider Business Mailing Address Fax Number:
914-962-8160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
JEFFERSON VALLEY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10535-1505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-962-8111
Provider Business Practice Location Address Fax Number:
914-962-8160
Provider Enumeration Date:
11/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLETT
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OD/SOLE OWNER
Authorized Official Telephone Number:
914-962-8111

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  VUT005605-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com