Provider Demographics
NPI:1821032699
Name:KEITHLY, KENT ALLEN (RPT)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:ALLEN
Last Name:KEITHLY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-6864
Mailing Address - Country:US
Mailing Address - Phone:580-237-6847
Mailing Address - Fax:580-237-0948
Practice Address - Street 1:522 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3842
Practice Address - Country:US
Practice Address - Phone:580-237-0905
Practice Address - Fax:580-237-0948
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00327766OtherRR MEDICARE
OK$$$$$$$$$OtherTRICARE
OKP00327766OtherRR MEDICARE
OK$$$$$$$$$003OtherBCBS