Provider Demographics
NPI:1356415392
Name:KECK, DIANE (LMT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 2ND AVE W APT 18
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-1744
Mailing Address - Country:US
Mailing Address - Phone:701-799-4174
Mailing Address - Fax:
Practice Address - Street 1:107 SHEYENNE ST
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1728
Practice Address - Country:US
Practice Address - Phone:701-281-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND718174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist