Provider Demographics
NPI:1548330434
Name:MCCARROLL, KEITH (PT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MCCARROLL
Suffix:
Gender:M
Credentials:PT
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 3381
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-3381
Mailing Address - Country:US
Mailing Address - Phone:970-949-9966
Mailing Address - Fax:970-949-9988
Practice Address - Street 1:100 W. BEAVER CREEK BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-949-9966
Practice Address - Fax:970-949-9988
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC800807Medicare PIN