Provider Demographics
NPI:1902930357
Name:CHRISTIANSEN, KEITH A
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 N INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7414
Mailing Address - Country:US
Mailing Address - Phone:386-917-1001
Mailing Address - Fax:386-917-1008
Practice Address - Street 1:177 N INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7414
Practice Address - Country:US
Practice Address - Phone:386-917-1001
Practice Address - Fax:386-917-1008
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2775156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician