Provider Demographics
NPI:1609555721
Name:KEENE, MITCHELL TERRY
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:TERRY
Last Name:KEENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HIGHWAY 274
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6045
Mailing Address - Country:US
Mailing Address - Phone:803-619-7025
Mailing Address - Fax:803-831-5049
Practice Address - Street 1:175 HIGHWAY 274
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-6045
Practice Address - Country:US
Practice Address - Phone:803-619-7025
Practice Address - Fax:803-831-5049
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician