Provider Demographics
NPI:1265912224
Name:FREE, KEITH JEROME
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JEROME
Last Name:FREE
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 1:8325 BLAKE ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:71033-3324
Mailing Address - Country:US
Mailing Address - Phone:318-218-0514
Mailing Address - Fax:
Practice Address - Street 1:4054 NW LOOP
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-3346
Practice Address - Country:US
Practice Address - Phone:903-693-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2052140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant