Healthcare Provider Details

I. General information

NPI: 1023944725
Provider Name (Legal Business Name): KEITH LY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

2425 CARSON ST APT 12
LAKEWOOD CA
90712-4121
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-1000
  • Fax:
Mailing address:
  • Phone: 408-332-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95237073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: