Provider Demographics
NPI:1568592806
Name:ROPER, KEITH LEROY (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:LEROY
Last Name:ROPER
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 1:37116 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURNEY
Mailing Address - State:CA
Mailing Address - Zip Code:96013-4127
Mailing Address - Country:US
Mailing Address - Phone:530-335-3206
Mailing Address - Fax:530-335-5383
Practice Address - Street 1:37116 MAIN ST
Practice Address - Street 2:
Practice Address - City:BURNEY
Practice Address - State:CA
Practice Address - Zip Code:96013-4127
Practice Address - Country:US
Practice Address - Phone:530-335-3206
Practice Address - Fax:530-335-5383
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0155050Medicaid
CAZZZ50827ZOtherBLUE SHIELD OF CA
CAZZZ05843ZOtherMEDICARE GROUP PTAN
CAPT0155050Medicaid