Provider Demographics
NPI:1801207667
Name:KECK, DAVID ANDREW (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:KECK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17162 MISTY WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST FORK
Mailing Address - State:AR
Mailing Address - Zip Code:72774-2840
Mailing Address - Country:US
Mailing Address - Phone:479-236-2389
Mailing Address - Fax:
Practice Address - Street 1:3801 JOHNSON MILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6364
Practice Address - Country:US
Practice Address - Phone:479-856-6400
Practice Address - Fax:479-856-6623
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant