Provider Demographics
NPI:1467948000
Name:KEITH, TYLER ROBERT (ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ROBERT
Last Name:KEITH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 OLD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1748
Mailing Address - Country:US
Mailing Address - Phone:774-276-1024
Mailing Address - Fax:
Practice Address - Street 1:504 ALBEMARLE SQ
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-7405
Practice Address - Country:US
Practice Address - Phone:434-817-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260026542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer