Healthcare Provider Details

I. General information

NPI: 1689592750
Provider Name (Legal Business Name): KEITH CHARLES SPOTTS RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60153 HATLEY RD
AMORY MS
38821-7210
US

IV. Provider business mailing address

60153 HATLEY RD
AMORY MS
38821-7210
US

V. Phone/Fax

Practice location:
  • Phone: 662-305-5077
  • Fax:
Mailing address:
  • Phone: 662-305-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberD0838
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD0838
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: