Healthcare Provider Details

I. General information

NPI: 1255776498
Provider Name (Legal Business Name): VIDA KELLER RISTON RN CNM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 CALDER ST
BEAUMONT TX
77702-1845
US

IV. Provider business mailing address

PO BOX 12667
BEAUMONT TX
77726-2667
US

V. Phone/Fax

Practice location:
  • Phone: 409-838-4472
  • Fax: 409-838-0496
Mailing address:
  • Phone: 409-838-4472
  • Fax: 409-838-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number540793
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number540793
License Number StateTX

VIII. Authorized Official

Name: MS. VIDA RISTON
Title or Position: CEO
Credential: FNP, CNM
Phone: 409-838-4472