1457478158 NPI number — KEYLON EYECARE, PC

Table of content: (NPI 1457478158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457478158 NPI number — KEYLON EYECARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYLON EYECARE, 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:
1457478158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O BOX 826
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37371-0826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-745-8882
Provider Business Mailing Address Fax Number:
423-744-8428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 W MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37303-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-745-8882
Provider Business Practice Location Address Fax Number:
423-744-8428
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KEYLON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-745-8882

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  503 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3724013 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com