MEDICARE: JOHN C KELLER MS, 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	6950	NC

General Provider Information

NPI Number	:	1639212145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN C KELLER MS, PT

Provider Business Mailing Address
First Line	:	4601 LAKE BOONE TRL STE 2E
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-7518
Country	:	US
Telephone Number	:	919-781-3978
Fax Number	:

Provider Business Practice Location Address
First Line	:	4601 LAKE BOONE TRL STE 2E
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-7518
Country	:	US
Telephone Number	:	919-781-3978
Fax Number	:

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/08/2007

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