Provider Demographics
NPI:1992254536
Name:CORBIN, KEITH MICHAEL (DPT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:CORBIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 BRISTOL ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5985
Mailing Address - Country:US
Mailing Address - Phone:714-966-2950
Mailing Address - Fax:
Practice Address - Street 1:2755 BRISTOL ST
Practice Address - Street 2:SUITE 130
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5985
Practice Address - Country:US
Practice Address - Phone:714-966-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist