Healthcare Provider Details

I. General information

NPI: 1215638531
Provider Name (Legal Business Name): OLIVIA KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 98TH AVE E
PARRISH FL
34219-4431
US

IV. Provider business mailing address

5005 98TH AVE E
PARRISH FL
34219-4431
US

V. Phone/Fax

Practice location:
  • Phone: 330-685-2730
  • Fax:
Mailing address:
  • Phone: 330-685-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND8213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: