Provider Demographics
NPI:1912675935
Name:COUTURE, KEILY (OD)
Entity Type:Individual
Prefix:
First Name:KEILY
Middle Name:
Last Name:COUTURE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13836 E FIERY DAWN DR
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-6456
Mailing Address - Country:US
Mailing Address - Phone:937-668-2180
Mailing Address - Fax:
Practice Address - Street 1:1599 J ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS AFB
Practice Address - State:ND
Practice Address - Zip Code:58205-6306
Practice Address - Country:US
Practice Address - Phone:937-668-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist