Provider Demographics
NPI:1063189835
Name:VIDAL, KEITH ALEXANDER
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALEXANDER
Last Name:VIDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 212041
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33421-2041
Mailing Address - Country:US
Mailing Address - Phone:757-231-6717
Mailing Address - Fax:
Practice Address - Street 1:11321 TORCHWOOD CT
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6024
Practice Address - Country:US
Practice Address - Phone:757-231-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA97864225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist