Provider Demographics
NPI:1457478158
Name:KEYLON EYECARE, PC
Entity Type:Organization
Organization Name:KEYLON EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KEYLON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-745-8882
Mailing Address - Street 1:P.O BOX 826
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-0826
Mailing Address - Country:US
Mailing Address - Phone:423-745-8882
Mailing Address - Fax:423-744-8428
Practice Address - Street 1:902 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3432
Practice Address - Country:US
Practice Address - Phone:423-745-8882
Practice Address - Fax:423-744-8428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3724013Medicaid
TN3724013Medicare ID - Type Unspecified
TN0350810001Medicare NSC