Provider Demographics
NPI:1578917878
Name:KEENE EYE CARE
Entity Type:Organization
Organization Name:KEENE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROETTIGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:603-357-4090
Mailing Address - Street 1:338 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-4146
Mailing Address - Country:US
Mailing Address - Phone:603-357-4090
Mailing Address - Fax:
Practice Address - Street 1:338 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-4146
Practice Address - Country:US
Practice Address - Phone:603-357-4090
Practice Address - Fax:603-357-5081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3097178Medicaid
NH3083011Medicaid