Provider Demographics
NPI:1982027488
Name:MANN, KEITH LOREN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:LOREN
Last Name:MANN
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 1:150 RIDGEWAY FARM DR
Mailing Address - Street 2:
Mailing Address - City:KESWICK
Mailing Address - State:VA
Mailing Address - Zip Code:22947-3037
Mailing Address - Country:US
Mailing Address - Phone:434-962-1662
Mailing Address - Fax:434-296-2367
Practice Address - Street 1:150 RIDGEWAY FARM DR
Practice Address - Street 2:
Practice Address - City:KESWICK
Practice Address - State:VA
Practice Address - Zip Code:22947
Practice Address - Country:US
Practice Address - Phone:434-962-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor