Provider Demographics
NPI:1588029441
Name:KECK, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:KECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-1351
Mailing Address - Country:US
Mailing Address - Phone:610-442-8495
Mailing Address - Fax:
Practice Address - Street 1:1919 GREENTREE RD STE B
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1115
Practice Address - Country:US
Practice Address - Phone:856-424-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-20
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00317200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant