Healthcare Provider Details

I. General information

NPI: 1134549595
Provider Name (Legal Business Name): PAUL KEKACS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3459 W 5400 S
ROY UT
84067-9255
US

IV. Provider business mailing address

3459 W 5400 S
ROY UT
84067-9255
US

V. Phone/Fax

Practice location:
  • Phone: 801-866-5478
  • Fax:
Mailing address:
  • Phone: 801-866-5478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8107628-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: