Provider Demographics
NPI:1457684847
Name:FLOCK, KEISHA (PSR TEAM LEAD)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:FLOCK
Suffix:
Gender:F
Credentials:PSR TEAM LEAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 SOUTH LOS LENTES ROAD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031
Mailing Address - Country:US
Mailing Address - Phone:505-865-3350
Mailing Address - Fax:
Practice Address - Street 1:428 SOUTH LOS LENTES RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8493
Practice Address - Country:US
Practice Address - Phone:505-865-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850294695OtherTAX ID