Provider Demographics
NPI:1083783476
Name:KEIL, SHANE (PT, OCS)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KEIL
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14068 COTTONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-2219
Mailing Address - Country:US
Mailing Address - Phone:970-522-7823
Mailing Address - Fax:
Practice Address - Street 1:427 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-3033
Practice Address - Country:US
Practice Address - Phone:970-522-7743
Practice Address - Fax:970-521-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO066589Medicare ID - Type Unspecified