Healthcare Provider Details

I. General information

NPI: 1356415392
Provider Name (Legal Business Name): DIANE KECK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SHEYENNE ST
WEST FARGO ND
58078-1728
US

IV. Provider business mailing address

219 2ND AVE W APT 18
WEST FARGO ND
58078-1744
US

V. Phone/Fax

Practice location:
  • Phone: 701-281-2777
  • Fax:
Mailing address:
  • Phone: 701-799-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number718
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: