Basic Information
| Provider Information | |||||||||
| NPI: | 1578876561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KEENAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 787 W ELBERON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907311801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107228125 | ||||||||
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| Practice Location | |||||||||
| Address1: | 370 CRENSHAW BLVD STE E100 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905031728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107871500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2010 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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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 | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.