Provider Demographics
NPI:1477616647
Name:FARLEY, KEITH G (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:FARLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 HOUSTON NORTHCUTT BLVD
Mailing Address - Street 2:PRIMARY CARE OPTOMETRY
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-881-2525
Mailing Address - Fax:843-881-2578
Practice Address - Street 1:855 HOUSTON NORTHCUTT BLVD
Practice Address - Street 2:PRIMARY CARE OPTOMETRY
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-881-2525
Practice Address - Fax:843-881-2578
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD00739Medicaid
SCDA9736Medicaid
T236190281Medicare ID - Type Unspecified
SCDA9736Medicaid