Provider Demographics
NPI:1235605338
Name:KECK, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:KECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 CATFISH LN
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19465-7305
Mailing Address - Country:US
Mailing Address - Phone:484-366-4022
Mailing Address - Fax:
Practice Address - Street 1:931 CATFISH LN
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19465-7305
Practice Address - Country:US
Practice Address - Phone:484-366-4022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA096084171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028954670003Medicaid