Provider Demographics
NPI:1861707317
Name:KEREKY, BRIAN JOHN (LPN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOHN
Last Name:KEREKY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 LAKE RD LOT 28
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-2946
Mailing Address - Country:US
Mailing Address - Phone:440-593-3919
Mailing Address - Fax:
Practice Address - Street 1:4017 LAKE RD LOT 28
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2946
Practice Address - Country:US
Practice Address - Phone:440-593-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN134320-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse