Provider Demographics
NPI:1760838726
Name:DORMAN SMITH, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DORMAN SMITH
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 1:6716 SNOWY RANGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-5192
Mailing Address - Country:US
Mailing Address - Phone:719-470-0227
Mailing Address - Fax:
Practice Address - Street 1:2910 N POWERS BLVD
Practice Address - Street 2:SUITE 139
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2801
Practice Address - Country:US
Practice Address - Phone:719-232-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLL-03194347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle