Provider Demographics
NPI:1174678452
Name:ROGERS, KEITH ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALLEN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 MANITO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-4013
Mailing Address - Country:US
Mailing Address - Phone:201-921-7766
Mailing Address - Fax:
Practice Address - Street 1:199 MANITO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-4013
Practice Address - Country:US
Practice Address - Phone:201-921-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00966100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist