Healthcare Provider Details

I. General information

NPI: 1083033641
Provider Name (Legal Business Name): CHRISTOPHER KECK LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 N CENTRAL AVE
PHOENIX AZ
85004-1455
US

IV. Provider business mailing address

2120 N CENTRAL AVE
PHOENIX AZ
85004-1455
US

V. Phone/Fax

Practice location:
  • Phone: 602-271-4500
  • Fax: 602-282-0102
Mailing address:
  • Phone: 602-271-4500
  • Fax: 602-282-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC13926
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: