Provider Demographics
NPI:1578876561
Name:DAVIS, KEENAN
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:
Last Name:DAVIS
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 1:787 W ELBERON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-1801
Mailing Address - Country:US
Mailing Address - Phone:310-722-8125
Mailing Address - Fax:
Practice Address - Street 1:370 CRENSHAW BLVD STE E100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1728
Practice Address - Country:US
Practice Address - Phone:310-787-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner