Healthcare Provider Details

I. General information

NPI: 1316911480
Provider Name (Legal Business Name): DOUGLAS EDWARD KEEN LAT,ATC,RTR
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W CARMEL DR SUITE 150
CARMEL IN
46032-5877
US

IV. Provider business mailing address

16720 YEOMAN WAY
WESTFIELD IN
46074-8092
US

V. Phone/Fax

Practice location:
  • Phone: 317-876-7503
  • Fax: 317-595-1190
Mailing address:
  • Phone: 317-867-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: