Provider Demographics
NPI:1972968683
Name:DEVITO, KEEGAN
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:
Last Name:DEVITO
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 1:531 COUNTY ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:RICHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13681-3107
Mailing Address - Country:US
Mailing Address - Phone:315-317-2966
Mailing Address - Fax:
Practice Address - Street 1:531 COUNTY ROUTE 20
Practice Address - Street 2:
Practice Address - City:RICHVILLE
Practice Address - State:NY
Practice Address - Zip Code:13681-3107
Practice Address - Country:US
Practice Address - Phone:315-317-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1000865151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist