MEDICARE: KELLER OPTOMETRIC, INC.

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	152W00000X	Optometrist	OPT10085T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477694214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLER OPTOMETRIC, INC.

Provider Business Mailing Address
First Line	:	36921 COOK ST
Second Line	:	SUITE 104
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6070
Country	:	US
Telephone Number	:	760-341-7373
Fax Number	:	760-341-8383

Provider Business Practice Location Address
First Line	:	36921 COOK ST
Second Line	:	SUITE 104
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6070
Country	:	US
Telephone Number	:	760-341-7373
Fax Number	:	760-341-8383

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHEN ROBERT KELLER
Credential	:	O.D.
Telephone Number	:	760-341-7373

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	09/18/2015

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Directions to “KELLER OPTOMETRIC, INC. ” Practice Location

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