Provider Demographics
NPI:1457564544
Name:BODLEY, KEITH CHARLES
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:CHARLES
Last Name:BODLEY
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:PO BOX 233322
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-3322
Mailing Address - Country:US
Mailing Address - Phone:907-868-8661
Mailing Address - Fax:907-868-8661
Practice Address - Street 1:12501 SILVER FOX LN
Practice Address - Street 2:APARTMENT NUMBER 1
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3527
Practice Address - Country:US
Practice Address - Phone:907-868-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM31561OtherINDIVIDUAL IDENTIFICATION
AKCMG616OtherAGENCY NUMBER
AK730834OtherSTATE LICENSE