Provider Demographics
NPI:1528213030
Name:VANSOELEN, KEITH ALLEN (ATC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:VANSOELEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 GRAND PARKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5258
Mailing Address - Country:US
Mailing Address - Phone:904-287-8179
Mailing Address - Fax:
Practice Address - Street 1:55TH AND GRANT STREETS
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-570-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 12582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer