Healthcare Provider Details

I. General information

NPI: 1356622773
Provider Name (Legal Business Name): SAMUEL DAVID KEETON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 LACKEY LN
RIPLEY TN
38063-1619
US

IV. Provider business mailing address

5322 SHETLAND TRL
ARLINGTON TN
38002-8366
US

V. Phone/Fax

Practice location:
  • Phone: 731-635-5100
  • Fax:
Mailing address:
  • Phone: 901-237-1726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2824
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: