Provider Demographics
NPI:1568517852
Name:KECK, KATHERINE SUE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUE
Last Name:KECK
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2179
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-4179
Mailing Address - Country:US
Mailing Address - Phone:606-248-6030
Mailing Address - Fax:606-248-0014
Practice Address - Street 1:2145 US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1874
Practice Address - Country:US
Practice Address - Phone:606-248-6030
Practice Address - Fax:606-248-0014
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 0478156FX1800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000072724OtherANTHEM BCBS
KYKY0478OtherEYEMED
KY000000072724OtherANTHEM BCBS
KY52904786Medicaid