1962998161 NPI number — KELLERLIFE, LLC

Table of content: (NPI 1962998161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962998161 NPI number — KELLERLIFE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLERLIFE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KELLERLIFE CENTER FOR EATING DISORDERS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962998161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 S HEARTHSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85226-5010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-656-1070
Provider Business Mailing Address Fax Number:
480-656-1231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S HEARTHSTONE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85226-5010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-239-3459
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
TODD
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
CLINICAL INFORMATICIST
Authorized Official Telephone Number:
480-294-1386

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com