Provider Demographics
NPI:1679843171
Name:CARREGAL, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:CARREGAL
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 1:365 SUMMERCOVE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5951
Mailing Address - Country:US
Mailing Address - Phone:904-315-8525
Mailing Address - Fax:
Practice Address - Street 1:365 SUMMERCOVE CIR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5951
Practice Address - Country:US
Practice Address - Phone:904-315-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-31
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist