Provider Demographics
NPI:1790291524
Name:KEITH, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 S TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5864
Mailing Address - Country:US
Mailing Address - Phone:716-438-2906
Mailing Address - Fax:
Practice Address - Street 1:5735 S TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5864
Practice Address - Country:US
Practice Address - Phone:716-438-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008735156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician