Healthcare Provider Details

I. General information

NPI: 1144404583
Provider Name (Legal Business Name): KEITH E DEYO LAT,ATC,CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GERMANTOWN RD
DANBURY CT
06810-5023
US

IV. Provider business mailing address

20 MIDWAY DR
BETHEL CT
06801-2230
US

V. Phone/Fax

Practice location:
  • Phone: 203-778-4773
  • Fax:
Mailing address:
  • Phone: 203-791-1976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000254
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: