Healthcare Provider Details

I. General information

NPI: 1982166047
Provider Name (Legal Business Name): DUSTIN KELLER ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1547 RED BOTTOM RD
BROOKNEAL VA
24528
US

IV. Provider business mailing address

1547 RED BOTTOM RD.
BROOKNEAL VA
24528
US

V. Phone/Fax

Practice location:
  • Phone: 434-610-8895
  • Fax:
Mailing address:
  • Phone: 434-610-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN TYE KELLER
Title or Position: OWNER/OPERATOR
Credential:
Phone: 434-610-8895