=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639444326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEITH B. NICE, OD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2012
-----------------------------------------------------
Last Update Date | 05/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2603 HOLLY HILL ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-228-1766
-----------------------------------------------------
Fax | 336-228-6432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2603 HOLLY HILL ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-5156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-228-1766
-----------------------------------------------------
Fax | 336-228-6432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEITH BYRON NICE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 336-228-1766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 200001781381
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------