Healthcare Provider Details

I. General information

NPI: 1801207667
Provider Name (Legal Business Name): DAVID ANDREW KECK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 JOHNSON MILL BLVD STE B
FAYETTEVILLE AR
72704-6364
US

IV. Provider business mailing address

17162 MISTY WOOD RD
WEST FORK AR
72774-2840
US

V. Phone/Fax

Practice location:
  • Phone: 479-856-6400
  • Fax: 479-856-6623
Mailing address:
  • Phone: 479-236-2389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2677
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: