Provider Demographics
NPI:1134254089
Name:BACKES, KEITH L (PT)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:L
Last Name:BACKES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 SUNFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-5602
Mailing Address - Country:US
Mailing Address - Phone:406-488-6494
Mailing Address - Fax:
Practice Address - Street 1:516 MAIN ST N
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:MT
Practice Address - Zip Code:58854-7310
Practice Address - Country:US
Practice Address - Phone:701-842-3000
Practice Address - Fax:701-842-6248
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND890OtherLICENSE NUMBER
MT558PTOtherLICENSE NUMBER