Provider Demographics
NPI:1740969856
Name:KIMMINAU, KEEGAN (DPT)
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
Last Name:KIMMINAU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:
Other - Last Name:KIMMINAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:222 TIMBER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LINN VALLEY
Mailing Address - State:KS
Mailing Address - Zip Code:66040-5396
Mailing Address - Country:US
Mailing Address - Phone:913-244-1690
Mailing Address - Fax:
Practice Address - Street 1:5345 MARIAN LN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1841
Practice Address - Country:US
Practice Address - Phone:757-456-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACP031999T225100000X
KS11-07283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty