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General NPI Number Information
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NPI Number | 1124780986
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Entity Type | Individual
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Provider Name | MR. MELTON RAY KEITH JR.
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Gender | Male
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Dates
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Enumeration Date | 10/08/2021
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Last Update Date | 10/08/2021
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Provider Practice Location Address
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Address Line | 4343 WILLIAMSBOURGH DR
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City | SACRAMENTO
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State | CA
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Zip | 95823-2006
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Country | US
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Telephone | 915-395-3552
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Fax |
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Provider Business Mailing Address
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Address Line | 5312 VALHALLA DR
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City | CARMICHAEL
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State | CA
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Zip | 95608-1243
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Country | US
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Telephone | 916-517-5960
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | R1438570721
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License Number State | CA
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