Provider Demographics
NPI:1295182293
Name:MADDOX, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MADDOX
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 1:230 CALM LAKE CIR
Mailing Address - Street 2:APT. A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2543
Mailing Address - Country:US
Mailing Address - Phone:585-483-1720
Mailing Address - Fax:
Practice Address - Street 1:230 CALM LAKE CIR
Practice Address - Street 2:APT. A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2543
Practice Address - Country:US
Practice Address - Phone:585-483-1720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251B00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management