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General NPI Number Information
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NPI Number | 1326190653
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Entity Type | Individual
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Provider Name | MAIKUTLO B KEBAETSE PH.D, P.T.
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Gender | Male
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 541 MANTUA AVE
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City | PAULSBORO
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State | NJ
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Zip | 08066-1178
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Country | US
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Telephone | 185-622-4000
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Fax | 856-224-0466
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Provider Business Mailing Address
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Address Line | PO BOX 277
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City | PAULSBORO
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State | NJ
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Zip | 08066-0277
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Country | US
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Telephone | 185-622-0400
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Fax | 856-224-0466
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 40QA00685900
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License Number State | NJ
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