Healthcare Provider Details

I. General information

NPI: 1689545519
Provider Name (Legal Business Name): KEILEN LEE DYKES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8551 HUNTERS TRL SE
WARREN OH
44484-2410
US

IV. Provider business mailing address

8551 HUNTERS TRL SE
WARREN OH
44484-2410
US

V. Phone/Fax

Practice location:
  • Phone: 740-802-1376
  • Fax:
Mailing address:
  • Phone: 740-802-1376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: