Healthcare Provider Details

I. General information

NPI: 1538635875
Provider Name (Legal Business Name): MICHELE KECK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 10/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 SPENARD RD
ANCHORAGE AK
99503
US

IV. Provider business mailing address

PO BOX 90715
ANCHORAGE AK
99509-0715
US

V. Phone/Fax

Practice location:
  • Phone: 907-764-4055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1155713
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: