Healthcare Provider Details

I. General information

NPI: 1720032139
Provider Name (Legal Business Name): KEISHA L BLACK RKT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 SPRINGRIDGE RD
GAUTIER MS
39553-3123
US

IV. Provider business mailing address

1603 SPRINGRIDGE RD
GAUTIER MS
39553-3123
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-8189
  • Fax:
Mailing address:
  • Phone: 228-497-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: