Provider Demographics
NPI:1851579056
Name:KEITH OLIVER DR
Entity Type:Organization
Organization Name:KEITH OLIVER DR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-372-4493
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-1119
Mailing Address - Country:US
Mailing Address - Phone:336-372-4493
Mailing Address - Fax:336-372-2035
Practice Address - Street 1:18 S GRAYSON ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-9598
Practice Address - Country:US
Practice Address - Phone:336-372-4493
Practice Address - Fax:336-372-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0712080001Medicare NSC