MEDICARE: MS. BEVERLY LOUISE KEELER RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD 3645	OH

General Provider Information

NPI Number	:	1023230984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BEVERLY LOUISE KEELER RD

Provider Business Mailing Address
First Line	:	3532 SILSBY RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3620
Country	:	US
Telephone Number	:	216-932-2309
Fax Number	:

Provider Business Practice Location Address
First Line	:	3532 SILSBY RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-3620
Country	:	US
Telephone Number	:	216-932-2309
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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