Provider Demographics
NPI:1962063172
Name:KELSEY WHITE, O.D., LLC
Entity type:Organization
Organization Name:KELSEY WHITE, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-857-3104
Mailing Address - Street 1:3250 S ARIZONA AVE APT 3037
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-2739
Mailing Address - Country:US
Mailing Address - Phone:479-857-3104
Mailing Address - Fax:
Practice Address - Street 1:1175 S ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6504
Practice Address - Country:US
Practice Address - Phone:480-726-0941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty