Healthcare Provider Details

I. General information

NPI: 1437295268
Provider Name (Legal Business Name): KEITH BRIAN RAYMOND P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

IV. Provider business mailing address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

V. Phone/Fax

Practice location:
  • Phone: 760-955-1777
  • Fax: 760-955-2356
Mailing address:
  • Phone: 760-955-1777
  • Fax: 760-955-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT30697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: