Healthcare Provider Details

I. General information

NPI: 1497270045
Provider Name (Legal Business Name): KEATON LEE MCCOY PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 N 6TH ST
TOMAHAWK WI
54487-1425
US

IV. Provider business mailing address

800 NE COLLEEN DR
LEES SUMMIT MO
64086-4916
US

V. Phone/Fax

Practice location:
  • Phone: 877-230-3885
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2017026960
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: