Basic Information
| Provider Information | |||||||||
| NPI: | 1225184328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEYS | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 MACOMB | ||||||||
| Address2: | |||||||||
| City: | MT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
| FaxNumber: | 5864641472 | ||||||||
| Practice Location | |||||||||
| Address1: | 5611 PRESTON HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029696222 | ||||||||
| FaxNumber: | 5029690285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1154DT | KY | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.