Provider Demographics
NPI:1912556069
Name:BACKMON, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BACKMON
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 1:5658 REX RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-5237
Mailing Address - Country:US
Mailing Address - Phone:404-849-9419
Mailing Address - Fax:678-586-3370
Practice Address - Street 1:5658 REX RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-5237
Practice Address - Country:US
Practice Address - Phone:404-849-9419
Practice Address - Fax:678-586-3370
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL-001113-2019343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)