MEDICARE: KELLIE RENEE KEENEY DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT010058	GA

General Provider Information

NPI Number	:	1063715274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE RENEE KEENEY DPT

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	1100 SHERWOOD PARK DR NE STE 140
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3426
Country	:	US
Telephone Number	:	770-297-7750
Fax Number	:	770-297-1026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2010
Last Update Date	:	05/07/2015

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