Healthcare Provider Details

I. General information

NPI: 1962730341
Provider Name (Legal Business Name): KEITH HURST RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 PARK PL
SWANSEA IL
62226-2967
US

IV. Provider business mailing address

9 PARK PL
SWANSEA IL
62226-2967
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-5722
  • Fax: 618-233-7069
Mailing address:
  • Phone: 618-233-5722
  • Fax: 618-233-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041283029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: