Basic Information
| Provider Information | |||||||||
| NPI: | 1467523043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEASLING | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | ATC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KEASLING | ||||||||
| OtherFirstName: | B. | ||||||||
| OtherMiddleName: | TODD | ||||||||
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| OtherCredential: | ATC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
| FaxNumber: | 9529469888 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
| FaxNumber: | 9529469888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/04/2016 | ||||||||
| NPIReactivationDate: | 01/19/2016 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1753 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.