Healthcare Provider Details

I. General information

NPI: 1265477111
Provider Name (Legal Business Name): NICK KEETER LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 MAYO DR
BARLING AR
72923-1660
US

IV. Provider business mailing address

10301 MAYO DR
BARLING AR
72923-1660
US

V. Phone/Fax

Practice location:
  • Phone: 479-494-5700
  • Fax: 479-494-5777
Mailing address:
  • Phone: 479-494-5700
  • Fax: 479-494-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA0606033
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: