Provider Demographics
NPI:1962061671
Name:KEKLAK, THADDEUS (DC)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:KEKLAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2105
Mailing Address - Country:US
Mailing Address - Phone:423-764-2663
Mailing Address - Fax:423-793-1100
Practice Address - Street 1:911 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2105
Practice Address - Country:US
Practice Address - Phone:423-764-2663
Practice Address - Fax:423-793-1100
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor