1700163839 NPI number — NICHOLAS J KELSEY

Table of content: (NPI 1700163839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700163839 NPI number — NICHOLAS J KELSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLAS J KELSEY
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:
CLARITY EYECARE
Provider Other Organization Name Type Code:
3
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:
1700163839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
928 TROTTER DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 BROADWAY AVE S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-944-9008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KELSEY
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OPTOMETRIS
Authorized Official Telephone Number:
208-731-8974

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODP-100146 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: ODP-100146 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: ODP-100146 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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