Healthcare Provider Details

I. General information

NPI: 1114943818
Provider Name (Legal Business Name): KEITH MICHAEL BELMORE DAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 COMMONWEALTH AVE
AUBURNDALE MA
02466-2709
US

IV. Provider business mailing address

142 JENKINS FARM RD
CHESTER NH
03036-4405
US

V. Phone/Fax

Practice location:
  • Phone: 617-243-2095
  • Fax:
Mailing address:
  • Phone: 603-767-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3494
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: