Healthcare Provider Details

I. General information

NPI: 1063341030
Provider Name (Legal Business Name): JUSTIN ARON KELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 WHITE OAK LN
UNIVERSITY PARK IL
60484-3007
US

IV. Provider business mailing address

920 WHITE OAK LN
UNIVERSITY PARK IL
60484-3007
US

V. Phone/Fax

Practice location:
  • Phone: 779-379-2636
  • Fax:
Mailing address:
  • Phone: 773-615-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.024466
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: