Provider Demographics
NPI:1457243149
Name:KELLER, KEVIN JAMES (CMT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:KELLER
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:JAMES
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:2420 RIVER RD STE 230-629
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-2268
Mailing Address - Country:US
Mailing Address - Phone:951-870-7034
Mailing Address - Fax:
Practice Address - Street 1:2420 RIVER RD STE 230-629
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2268
Practice Address - Country:US
Practice Address - Phone:951-870-7034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist