MEDICARE: TRACY L KELLER PT

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	225100000X	Physical Therapist	1141	ND
2	225100000X	Physical Therapist	7331	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DA9011015523	OTHER	ND	PREFERRED ONE #
3	HP53308	OTHER	ND	HEALTHPARTNERS #
4	26770	OTHER	ND	NDBS #
5	6406051	OTHER	ND	MEDICA #
6	037H4LU	OTHER	ND	MNBS #

General Provider Information

NPI Number	:	1629015300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY L KELLER PT

Provider Business Mailing Address
First Line	:	PO BOX 2010
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58122-2484
Country	:	US
Telephone Number	:	701-234-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3905
Country	:	US
Telephone Number	:	218-846-2000
Fax Number	:

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	11/20/2017

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Directions to “ TRACY L KELLER PT” Practice Location

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