MEDICARE: BONITA KEELING M.P.T.. PCS

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	225100000X	Physical Therapist	1122315	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	84132T, 63657	OTHER	TX	BCBS PAR, BCBS BLUE LINK

General Provider Information

NPI Number	:	1508937913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONITA KEELING M.P.T.. PCS

Provider Business Mailing Address
First Line	:	19142 BIG TIMBER ROAD
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703
Country	:	US
Telephone Number	:	903-780-3505
Fax Number	:

Provider Business Practice Location Address
First Line	:	3310 S BROADWAY AVE STE 100I
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-7818
Country	:	US
Telephone Number	:	903-781-1832
Fax Number	:	877-798-4959

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	11/12/2024

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