Provider Demographics
NPI:1275516155
Name:KEITH R MOULDS OD PC
Entity Type:Organization
Organization Name:KEITH R MOULDS OD PC
Other - Org Name:ALPHINE FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOULDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-784-8700
Mailing Address - Street 1:4643 ALPINE AVE NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8179
Mailing Address - Country:US
Mailing Address - Phone:616-784-8700
Mailing Address - Fax:616-784-8708
Practice Address - Street 1:4643 ALPINE AVE NW
Practice Address - Street 2:SUITE A
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8179
Practice Address - Country:US
Practice Address - Phone:616-784-8700
Practice Address - Fax:616-784-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4870110001Medicare NSC
MIMI5371Medicare PIN