Provider Demographics
NPI:1720513153
Name:KEENAN, MICHAEL P (OWNER, KMFITNESS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:KEENAN
Suffix:
Gender:M
Credentials:OWNER, KMFITNESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736
Mailing Address - Country:US
Mailing Address - Phone:732-292-1333
Mailing Address - Fax:
Practice Address - Street 1:93 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736
Practice Address - Country:US
Practice Address - Phone:732-292-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174H00000X174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMEDICAIDMedicaid