Provider Demographics
NPI:1245599356
Name:KEENAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KEENAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1281
Mailing Address - Country:US
Mailing Address - Phone:617-391-0088
Mailing Address - Fax:617-391-0068
Practice Address - Street 1:681 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1281
Practice Address - Country:US
Practice Address - Phone:617-391-0088
Practice Address - Fax:617-391-0068
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4786156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician