Healthcare Provider Details

I. General information

NPI: 1629260757
Provider Name (Legal Business Name): KEITH A. STOSE MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 MASON AVE
DAYTONA BEACH FL
32117-4611
US

IV. Provider business mailing address

1075 MASON AVE
DAYTONA BEACH FL
32117-4611
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-258-3561
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-258-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT16854
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: