Provider Demographics
NPI:1922089168
Name:KEITHLY REHAB PLLC
Entity Type:Organization
Organization Name:KEITHLY REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KEITHLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:580-237-0905
Mailing Address - Street 1:522 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3842
Mailing Address - Country:US
Mailing Address - Phone:580-237-0905
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-06
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDH0005OtherRAILROAD MEDICARE
OK=========OtherTRICARE
OKDH0005OtherRAILROAD MEDICARE
OKDH0005OtherRAILROAD MEDICARE