Provider Demographics
NPI:1528300506
Name:KECK, SUSAN (RN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29832-2733
Mailing Address - Country:US
Mailing Address - Phone:803-275-1768
Mailing Address - Fax:803-275-1764
Practice Address - Street 1:1131 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:SC
Practice Address - Zip Code:29832-2733
Practice Address - Country:US
Practice Address - Phone:803-275-1768
Practice Address - Fax:803-275-1764
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33919251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)