Healthcare Provider Details

I. General information

NPI: 1649531328
Provider Name (Legal Business Name): KEITH BLACKWELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 W 7TH AVE
EUGENE OR
97402-4616
US

IV. Provider business mailing address

1166 W 7TH AVE
EUGENE OR
97402-4616
US

V. Phone/Fax

Practice location:
  • Phone: 458-210-2940
  • Fax: 541-654-4680
Mailing address:
  • Phone: 458-210-2940
  • Fax: 541-654-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3956
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3956
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: