Provider Demographics
NPI:1952844755
Name:GATZKA, KEIR (LMT)
Entity Type:Individual
Prefix:
First Name:KEIR
Middle Name:
Last Name:GATZKA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 GARLAND RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9037
Mailing Address - Country:US
Mailing Address - Phone:248-770-2367
Mailing Address - Fax:
Practice Address - Street 1:540 GARLAND RD
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-9037
Practice Address - Country:US
Practice Address - Phone:248-770-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501004167OtherMASSAGE THERAPIST LICENSE