Provider Demographics
NPI:1124437496
Name:KECK, TREVOR (OD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:KECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:357 W MORGAN ST STE C
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460-1255
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003878A152W00000X
MI4901004865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist