Healthcare Provider Details

I. General information

NPI: 1255536785
Provider Name (Legal Business Name): ELLIOTT SPENCER KECK IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 TOMCAT BLVD STE 150 NAS OCEANA, BHC
VIRGINIA BEACH VA
23460-2186
US

IV. Provider business mailing address

1550 TOMCAT BLVD STE 150 NAS OCEANA, BHC
VIRGINIA BEACH VA
23460-2186
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3792
  • Fax:
Mailing address:
  • Phone: 757-953-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: