Healthcare Provider Details

I. General information

NPI: 1861190332
Provider Name (Legal Business Name): CARL KEETON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 COLLINS RD NW
LANCASTER OH
43130-8815
US

IV. Provider business mailing address

1434 COLLINS RD NW
LANCASTER OH
43130-8815
US

V. Phone/Fax

Practice location:
  • Phone: 614-704-5690
  • Fax:
Mailing address:
  • Phone: 614-704-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003855
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: