Healthcare Provider Details

I. General information

NPI: 1760084313
Provider Name (Legal Business Name): STONE WILLIAM KELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W EAU GALLIE BLVD STE 105
MELBOURNE FL
32935-3166
US

IV. Provider business mailing address

782 READING ST SE
PALM BAY FL
32909-7228
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-2818
  • Fax:
Mailing address:
  • Phone: 321-750-6301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30576
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: