MEDICARE: MR. SAMUEL RAY KELLER PEER SUPPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1437955689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL RAY KELLER PEER SUPPORT

Provider Business Mailing Address
First Line	:	964 SE TERRACE DR
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-4330
Country	:	US
Telephone Number	:	909-533-9377
Fax Number	:

Provider Business Practice Location Address
First Line	:	1939 NE DIAMOND LAKE BLVD
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-3573
Country	:	US
Telephone Number	:	541-957-5646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2025
Last Update Date	:	02/19/2025

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