1700877206 NPI number — KEENE MEDICAL PRODUCTS, LLC

Table of content: (NPI 1700877206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700877206 NPI number — KEENE MEDICAL PRODUCTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEENE MEDICAL PRODUCTS, LLC
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:
6
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:
1700877206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 W GERMANTOWN PIKE STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH MEETING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19462-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-630-6357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 LANDING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03748-3545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-448-5225
Provider Business Practice Location Address Fax Number:
603-442-6000
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSALESI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER/ AO
Authorized Official Telephone Number:
484-246-9499

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  02866 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 007038 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1004915 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00489818 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13936000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80547038 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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