=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376872945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG KELLER ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2009
-----------------------------------------------------
Last Update Date | 01/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 177 GRANNY RD
-----------------------------------------------------
City | FARMINGVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11738-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-716-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 849 SAYVILLE AVE
-----------------------------------------------------
City | BOHEMIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11716-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------