Healthcare Provider Details

I. General information

NPI: 1154209211
Provider Name (Legal Business Name): MR. KEITH MWAYE EKWESE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SHOSHONE CIR
KATHLEEN GA
31047-5319
US

IV. Provider business mailing address

102 SHOSHONE CIR
KATHLEEN GA
31047-5319
US

V. Phone/Fax

Practice location:
  • Phone: 320-237-6466
  • Fax: 320-237-6466
Mailing address:
  • Phone: 320-237-6466
  • Fax: 320-237-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-467180
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: