Provider Demographics
NPI:1467421107
Name:PADDOCK, KEITH LOUIS (PT)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LOUIS
Last Name:PADDOCK
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 1:3327 ARCADE ST S
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-5002
Mailing Address - Country:US
Mailing Address - Phone:651-765-1764
Mailing Address - Fax:
Practice Address - Street 1:2104 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3005
Practice Address - Country:US
Practice Address - Phone:763-755-5495
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist