Provider Demographics
NPI:1255536785
Name:KECK, ELLIOTT SPENCER (IDC)
Entity type:Individual
Prefix:MR
First Name:ELLIOTT
Middle Name:SPENCER
Last Name:KECK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 TOMCAT BLVD STE 150
Mailing Address - Street 2:NAS OCEANA, BHC
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23460-2186
Mailing Address - Country:US
Mailing Address - Phone:757-953-3792
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD STE 150
Practice Address - Street 2:NAS OCEANA, BHC
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2186
Practice Address - Country:US
Practice Address - Phone:757-953-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other