Healthcare Provider Details

I. General information

NPI: 1487868717
Provider Name (Legal Business Name): KEVIN M KEENAN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S. BRIDGE STREET
BELLAIRE MI
49615
US

IV. Provider business mailing address

PO BOX 1020
BELLAIRE MI
49615-1020
US

V. Phone/Fax

Practice location:
  • Phone: 231-533-6113
  • Fax: 231-533-5049
Mailing address:
  • Phone: 231-533-6113
  • Fax: 231-533-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501003806
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: