Provider Demographics
NPI:1467510727
Name:KEENAN RUSSELL & MOORE INC
Entity Type:Organization
Organization Name:KEENAN RUSSELL & MOORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JABLONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:203-866-2775
Mailing Address - Street 1:650 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-4020
Mailing Address - Country:US
Mailing Address - Phone:203-866-2775
Mailing Address - Fax:
Practice Address - Street 1:650 WEST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-4020
Practice Address - Country:US
Practice Address - Phone:203-866-2775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001177156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004036364Medicaid
0297600001Medicare ID - Type Unspecified
CT004036364Medicaid