Healthcare Provider Details

I. General information

NPI: 1588230429
Provider Name (Legal Business Name): LUCAS KELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 E GENTRY WAY STE 180
MERIDIAN ID
83642-3014
US

IV. Provider business mailing address

17850 28TH ST NW
BALDWIN ND
58521-9773
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3334
  • Fax:
Mailing address:
  • Phone: 701-471-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-7368
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: