Provider Demographics
NPI:1619620341
Name:HART, KEOKA (CDL CLASS A)
Entity Type:Individual
Prefix:
First Name:KEOKA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:CDL CLASS A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46396 JENKINS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3508
Mailing Address - Country:US
Mailing Address - Phone:504-930-1276
Mailing Address - Fax:
Practice Address - Street 1:46406 JENKINS RD.
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438
Practice Address - Country:US
Practice Address - Phone:504-930-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10065508172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty