Basic Information
| Provider Information | |||||||||
| NPI: | 1639494594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLINSWORTH | ||||||||
| FirstName: | KEITH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD #7440 | ||||||||
| Address2: | BASSETT ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997037440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615418 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | BASSETT ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615418 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
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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 | 225100000X | PLT-10415 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.