Provider Demographics
NPI:1053746743
Name:KEIBEL, CHRISTOPHER (PTA)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:
Last Name:KEIBEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2018
Mailing Address - Country:US
Mailing Address - Phone:631-428-0368
Mailing Address - Fax:
Practice Address - Street 1:1133 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-2918
Practice Address - Country:US
Practice Address - Phone:631-399-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008649-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist