Provider Demographics
NPI:1043362213
Name:KEYS, KIMBERLY A (DC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:KEYS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9536 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9517
Mailing Address - Country:US
Mailing Address - Phone:260-420-8803
Mailing Address - Fax:
Practice Address - Street 1:2422 LAKE AVE
Practice Address - Street 2:PARK LAKE MEDICAL BUILDING
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5406
Practice Address - Country:US
Practice Address - Phone:260-420-8803
Practice Address - Fax:260-420-6814
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001845A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000190008OtherANTHEM BCBS
INU81109Medicare UPIN
IN152800AMedicare ID - Type Unspecified