Provider Demographics
NPI:1851760201
Name:LAYSON, KEITH MEDALLE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:MEDALLE
Last Name:LAYSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:505 N 5TH ST APT I
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4728
Mailing Address - Country:US
Mailing Address - Phone:618-993-4024
Mailing Address - Fax:618-993-1570
Practice Address - Street 1:3308 LOGAN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3759
Practice Address - Country:US
Practice Address - Phone:618-993-4024
Practice Address - Fax:618-993-1570
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist