Provider Demographics
NPI:1184073157
Name:DIERS, KEITH HENRY (PT DPT ATC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:HENRY
Last Name:DIERS
Suffix:
Gender:M
Credentials:PT DPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11091 JASON AVE NW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301
Mailing Address - Country:US
Mailing Address - Phone:763-744-4140
Mailing Address - Fax:
Practice Address - Street 1:11091 JASON AVE NW
Practice Address - Street 2:SUITE 2
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301
Practice Address - Country:US
Practice Address - Phone:763-744-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4831225100000X
MN102772251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist