Provider Demographics
NPI:1760378095
Name:KEITA, SIRE
Entity type:Individual
Prefix:
First Name:SIRE
Middle Name:
Last Name:KEITA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15780 W SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0030
Mailing Address - Country:US
Mailing Address - Phone:623-632-7473
Mailing Address - Fax:
Practice Address - Street 1:15780 W SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-0030
Practice Address - Country:US
Practice Address - Phone:623-632-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities