Provider Demographics
NPI:1548481559
Name:KELLER CHIROPRACTIC LLC
Entity type:Organization
Organization Name:KELLER CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:419-698-2008
Mailing Address - Street 1:3555 NAVARRE AVE
Mailing Address - Street 2:#4
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3459
Mailing Address - Country:US
Mailing Address - Phone:419-698-2008
Mailing Address - Fax:419-698-2640
Practice Address - Street 1:3555 NAVARRE AVE
Practice Address - Street 2:#4
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3459
Practice Address - Country:US
Practice Address - Phone:419-698-2008
Practice Address - Fax:419-698-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4066521Medicaid
OH4066521Medicaid