MEDICARE: KEITH LANSTOR RIGGINS JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		OK

General Provider Information

NPI Number	:	1366163784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH LANSTOR RIGGINS JR.

Provider Business Mailing Address
First Line	:	12200 HERITAGE PARK RD APT 265
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7518
Country	:	US
Telephone Number	:	717-542-3149
Fax Number	:

Provider Business Practice Location Address
First Line	:	12200 HERITAGE PARK RD APT 265
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-7518
Country	:	US
Telephone Number	:	717-542-3149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2022
Last Update Date	:	09/05/2022

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