Provider Demographics
NPI:1750893293
Name:HARDY, KEIVIA LATRICE
Entity type:Individual
Prefix:
First Name:KEIVIA
Middle Name:LATRICE
Last Name:HARDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7036 BUCKRAM OAK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6724
Mailing Address - Country:US
Mailing Address - Phone:334-324-9224
Mailing Address - Fax:
Practice Address - Street 1:3362 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2702
Practice Address - Country:US
Practice Address - Phone:334-324-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1215031744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management