Provider Demographics
NPI:1336693977
Name:MIMS, KEITH L
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:L
Last Name:MIMS
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 1:825 GREEN RD APT 304
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3471
Mailing Address - Country:US
Mailing Address - Phone:248-802-5854
Mailing Address - Fax:
Practice Address - Street 1:825 GREEN RD APT 304
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3471
Practice Address - Country:US
Practice Address - Phone:248-802-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other