Provider Demographics
NPI:1205016136
Name:KEENE CLINIC
Entity Type:Organization
Organization Name:KEENE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ-ANDUJO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:303-732-4268
Mailing Address - Street 1:190 S MAIN STREET
Mailing Address - Street 2:PO BOX 559
Mailing Address - City:KEENESBURG
Mailing Address - State:CO
Mailing Address - Zip Code:80643-0559
Mailing Address - Country:US
Mailing Address - Phone:303-732-4268
Mailing Address - Fax:303-732-9288
Practice Address - Street 1:190 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:KEENESBURG
Practice Address - State:CO
Practice Address - Zip Code:80643-0559
Practice Address - Country:US
Practice Address - Phone:303-732-4268
Practice Address - Fax:303-732-9288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC414808Medicare PIN