Basic Information
| Provider Information | |||||||||
| NPI: | 1346544269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | WENDELL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 INDUSTRIAL AVE APT 2 | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903023347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593899697 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7170 N FINANCIAL DR STE 135 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.