Healthcare Provider Details

I. General information

NPI: 1760496400
Provider Name (Legal Business Name): KEITH ALLEN DAGENHART LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7770 SW ALESON ROAD
PORTLAND OR
97223
US

IV. Provider business mailing address

38795 DUBALKO ROAD
SANDY OR
97055
US

V. Phone/Fax

Practice location:
  • Phone: 503-245-2752
  • Fax:
Mailing address:
  • Phone: 503-668-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7232
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: