Provider Demographics
NPI:1578310652
Name:KEEN, MARK BERNARD
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:BERNARD
Last Name:KEEN
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 1:515 FAIRFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3619
Mailing Address - Country:US
Mailing Address - Phone:786-715-7845
Mailing Address - Fax:
Practice Address - Street 1:515 FAIRFIELD WAY
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3619
Practice Address - Country:US
Practice Address - Phone:786-715-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84-4617478171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications