Healthcare Provider Details

I. General information

NPI: 1730527482
Provider Name (Legal Business Name): CHARLES FREDRICK KELLER CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S PRATT AVE
CARSON CITY NV
89701-4730
US

IV. Provider business mailing address

205 S PRATT AVE
CARSON CITY NV
89701-4730
US

V. Phone/Fax

Practice location:
  • Phone: 775-882-3945
  • Fax: 775-882-6126
Mailing address:
  • Phone: 775-882-3945
  • Fax: 775-882-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number00171-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: