Provider Demographics
NPI:1548280365
Name:RILEY, KELLY MONIQUE (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MONIQUE
Last Name:RILEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWNFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:79316
Mailing Address - Country:US
Mailing Address - Phone:806-637-3937
Mailing Address - Fax:
Practice Address - Street 1:114 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BROWNFIELD
Practice Address - State:TX
Practice Address - Zip Code:79316
Practice Address - Country:US
Practice Address - Phone:806-637-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6923TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1824039-02Medicaid
TX1824039-02Medicaid