Healthcare Provider Details

I. General information

NPI: 1487636510
Provider Name (Legal Business Name): JASON ALLEN KEESEE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 SOCASTEE BLVD
MYRTLE BEACH SC
29588-7221
US

IV. Provider business mailing address

729 HAWTHORN DR
PAWLEYS ISLAND SC
29585-8008
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-2513
  • Fax: 843-293-9059
Mailing address:
  • Phone: 843-235-2930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number221
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: