Provider Demographics
NPI:1598142002
Name:KEENE, DAVID (LMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KEENE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3550
Mailing Address - Country:US
Mailing Address - Phone:570-419-2779
Mailing Address - Fax:
Practice Address - Street 1:460 MARKET ST STE 208
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6322
Practice Address - Country:US
Practice Address - Phone:570-419-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG001962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA76-0749020Medicaid
PA76-0749020Medicare UPIN
PA76-0749020Medicaid