Provider Demographics
NPI:1114943818
Name:BELMORE, KEITH MICHAEL (DAT, ATC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:BELMORE
Suffix:
Gender:M
Credentials:DAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 JENKINS FARM RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03036-4405
Mailing Address - Country:US
Mailing Address - Phone:603-767-8930
Mailing Address - Fax:
Practice Address - Street 1:1844 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2709
Practice Address - Country:US
Practice Address - Phone:617-243-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer