Healthcare Provider Details

I. General information

NPI: 1649508755
Provider Name (Legal Business Name): KEITH DEAGOSTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3072 W 300 N SUITE A
WEST POINT UT
84015-3933
US

IV. Provider business mailing address

3072 W 300 N SUITE A
WEST POINT UT
84015-3933
US

V. Phone/Fax

Practice location:
  • Phone: 914-623-8375
  • Fax:
Mailing address:
  • Phone: 914-623-8375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number345428-2401
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number345428-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: