Provider Demographics
NPI:1972174282
Name:VALENTINE, KEITH R
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:VALENTINE
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 1:4740 NELSON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5383
Mailing Address - Country:US
Mailing Address - Phone:512-586-6250
Mailing Address - Fax:
Practice Address - Street 1:4740 NELSON RD STE 110
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5383
Practice Address - Country:US
Practice Address - Phone:512-586-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date: