Healthcare Provider Details

I. General information

NPI: 1447642806
Provider Name (Legal Business Name): ASHLEY NICOLE KECK MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 CLEARWATER AVE
BLOOMINGTON IL
61704-8190
US

IV. Provider business mailing address

2811 CLEARWATER AVE
BLOOMINGTON IL
61704-8190
US

V. Phone/Fax

Practice location:
  • Phone: 574-361-9008
  • Fax:
Mailing address:
  • Phone: 574-361-9008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.003425
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: