Provider Demographics
NPI:1063834703
Name:CLOVIS, KEENAN (PTA)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:
Last Name:CLOVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E.12707 MASFIELD AVE APT# B301
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216
Mailing Address - Country:US
Mailing Address - Phone:409-499-2240
Mailing Address - Fax:
Practice Address - Street 1:E.12707 MASFIELD AVE APT# B301
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216
Practice Address - Country:US
Practice Address - Phone:409-499-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60234082225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant