Provider Demographics
NPI:1366402232
Name:KEISTER, KENNETH S (ATC,)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:S
Last Name:KEISTER
Suffix:
Gender:M
Credentials:ATC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5154
Mailing Address - Country:US
Mailing Address - Phone:407-256-8485
Mailing Address - Fax:
Practice Address - Street 1:2500 W TAFT VINELAND RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7818
Practice Address - Country:US
Practice Address - Phone:407-816-5600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer