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General NPI Number Information
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NPI Number | 1659723989
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Entity Type | Individual
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Provider Name | JUSTIN D KELLER D.C.
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Gender | Male
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Dates
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Enumeration Date | 07/11/2016
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Last Update Date | 09/28/2016
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Provider Practice Location Address
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Address Line | 3510 12TH ST 200
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City | LEWISTON
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State | ID
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Zip | 83501-5575
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Country | US
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Telephone | 208-799-3333
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Fax | 208-799-3375
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Provider Business Mailing Address
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Address Line | 18919 DOUBLE T LN
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City | LENORE
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State | ID
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Zip | 83541-6088
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Country | US
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Telephone | 208-816-3365
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Fax | 208-799-3375
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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 | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | CHIN-1718
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-1739
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License Number State | ID
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