Provider Demographics
NPI:1255911368
Name:KEEN IMMEDIATE CARE CLINIC
Entity type:Organization
Organization Name:KEEN IMMEDIATE CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OSEDO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:901-283-4637
Mailing Address - Street 1:5243 RIVERSIDE DR APT 1502
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-0869
Mailing Address - Country:US
Mailing Address - Phone:901-283-4637
Mailing Address - Fax:
Practice Address - Street 1:749 RIVERSIDE DRIVE LN
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2658
Practice Address - Country:US
Practice Address - Phone:478-832-2265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty