Provider Demographics
NPI:1811604853
Name:HENRY, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HENRY
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 1:301 S MC DOWELL ST
Mailing Address - Street 2:SUITE#125
Mailing Address - City:CHARLOTTE
Mailing Address - State:ND
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:917-443-7459
Mailing Address - Fax:
Practice Address - Street 1:301 S MC DOWELL STEETS
Practice Address - Street 2:SUITE125-1572
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:917-443-7459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider