Healthcare Provider Details

I. General information

NPI: 1962061671
Provider Name (Legal Business Name): THADDEUS KEKLAK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 ANDERSON ST
BRISTOL TN
37620-2105
US

IV. Provider business mailing address

911 ANDERSON ST
BRISTOL TN
37620-2105
US

V. Phone/Fax

Practice location:
  • Phone: 423-764-2663
  • Fax: 423-793-1100
Mailing address:
  • Phone: 423-764-2663
  • Fax: 423-793-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC011478
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: