Provider Demographics
NPI:1649035312
Name:HA, KELLEY (OD)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13621 IOWA ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15315 MAGNOLIA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1173
Practice Address - Country:US
Practice Address - Phone:805-230-2126
Practice Address - Fax:805-230-2199
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35635-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist