Provider Demographics
NPI:1013293257
Name:GREENE, KEVIN ALAN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:GREENE
Suffix:
Gender:M
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 176
Mailing Address - Street 2:56 LAKE ST
Mailing Address - City:PORT KENT
Mailing Address - State:NY
Mailing Address - Zip Code:12975-0176
Mailing Address - Country:US
Mailing Address - Phone:518-578-0425
Mailing Address - Fax:
Practice Address - Street 1:210 CORNELIA ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2318
Practice Address - Country:US
Practice Address - Phone:515-561-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7991156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician