Provider Demographics
NPI:1396396586
Name:KEOUGH, KEVIN EUGENE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EUGENE
Last Name:KEOUGH
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 1:3181 PINTAIL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-5543
Mailing Address - Country:US
Mailing Address - Phone:760-505-2516
Mailing Address - Fax:
Practice Address - Street 1:3181 PINTAIL DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-5543
Practice Address - Country:US
Practice Address - Phone:760-505-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider