Healthcare Provider Details

I. General information

NPI: 1306222575
Provider Name (Legal Business Name): KEITH KUPIEC DPT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 RIVERSIDE ST
NASHUA NH
03062-1396
US

IV. Provider business mailing address

29 RIVERSIDE ST
NASHUA NH
03062-1396
US

V. Phone/Fax

Practice location:
  • Phone: 603-881-9990
  • Fax:
Mailing address:
  • Phone: 603-881-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4011
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: