Provider Demographics
NPI:1447004783
Name:BLUEFORD, KEIMONTE LEMAR SR (MT)
Entity type:Individual
Prefix:
First Name:KEIMONTE
Middle Name:LEMAR
Last Name:BLUEFORD
Suffix:SR
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16551 N DYSART RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-3713
Mailing Address - Country:US
Mailing Address - Phone:480-397-1377
Mailing Address - Fax:
Practice Address - Street 1:16551 N DYSART RD STE 108
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-3713
Practice Address - Country:US
Practice Address - Phone:480-397-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24433225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist