Provider Demographics
NPI:1659413193
Name:KEELE, MARK DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:KEELE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 TAYLOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2542
Mailing Address - Country:US
Mailing Address - Phone:502-367-7114
Mailing Address - Fax:502-367-7108
Practice Address - Street 1:4011 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2542
Practice Address - Country:US
Practice Address - Phone:502-367-7114
Practice Address - Fax:502-367-7108
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051682OtherANTHEM BCBS
KY1121409OtherPASSPORT
KY85041978Medicaid
KY1121409OtherPASSPORT
KY85041978Medicaid