Provider Demographics
NPI:1801927546
Name:KEITH FAMILY VISION CLINIC
Entity type:Organization
Organization Name:KEITH FAMILY VISION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-283-7300
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-283-7300
Mailing Address - Fax:423-283-4729
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-283-7300
Practice Address - Fax:423-283-4729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT1679152W00000X
TNT1320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1257970001Medicare NSC
TN3945168Medicare ID - Type Unspecified