Healthcare Provider Details

I. General information

NPI: 1659723989
Provider Name (Legal Business Name): JUSTIN D KELLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 12TH ST 200
LEWISTON ID
83501-5575
US

IV. Provider business mailing address

18919 DOUBLE T LN
LENORE ID
83541-6088
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-3333
  • Fax: 208-799-3375
Mailing address:
  • Phone: 208-816-3365
  • Fax: 208-799-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1739
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIN-1718
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: