Healthcare Provider Details

I. General information

NPI: 1649186685
Provider Name (Legal Business Name): MRS. KEISHA DIANE GOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 DANIEL BOONE PLZ
HAZARD KY
41701-5335
US

IV. Provider business mailing address

120 DANIEL BOONE PLZ
HAZARD KY
41701-5335
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-0244
  • Fax: 606-487-0279
Mailing address:
  • Phone: 606-487-0244
  • Fax: 606-487-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number310759
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: