Provider Demographics
NPI:1669481123
Name:KEITH, KIM L (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:KEITH
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 1:6907 E PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1577
Mailing Address - Country:US
Mailing Address - Phone:623-546-4449
Mailing Address - Fax:623-546-4480
Practice Address - Street 1:19424 N R H JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-1409
Practice Address - Country:US
Practice Address - Phone:623-546-4449
Practice Address - Fax:623-546-4480
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ780917Medicaid
AZ101027Medicare ID - Type Unspecified