Provider Demographics
NPI:1588797450
Name:HARSTON, KEITH P (DC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:P
Last Name:HARSTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1855
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95634-1855
Mailing Address - Country:US
Mailing Address - Phone:530-333-4658
Mailing Address - Fax:
Practice Address - Street 1:2776 MINERS FLAT ROAD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:CA
Practice Address - Zip Code:95634-1855
Practice Address - Country:US
Practice Address - Phone:530-333-4658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU31373Medicare UPIN
CADC0191390Medicare ID - Type Unspecified