1043235989 NPI number — AKSEL KEKLIK PA

Table of content: AKSEL KEKLIK PA (NPI 1043235989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043235989 NPI number — AKSEL KEKLIK PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEKLIK
Provider First Name:
AKSEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043235989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 DISCOVERY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-3843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-5145
Provider Business Mailing Address Fax Number:
757-312-0216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 BURNETTS WAY
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-8168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-547-5145
Provider Business Practice Location Address Fax Number:
757-539-7488
Provider Enumeration Date:
07/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0110001528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49849053 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".