Healthcare Provider Details

I. General information

NPI: 1639544307
Provider Name (Legal Business Name): KEANU BEN TOHANNIE CERTIFIED MEDICAL AS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 NORTH MAIN STREET
TUBA CITY AZ
86045-0600
US

IV. Provider business mailing address

PO BOX 600
TUBA CITY AZ
86045-0600
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2094
  • Fax: 928-283-2677
Mailing address:
  • Phone: 928-283-2094
  • Fax: 928-283-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberE8L6X2B3
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: