1053346171 NPI number — TRISTAN GLENN KELLER LISW

Table of content: TRISTAN GLENN KELLER LISW (NPI 1053346171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053346171 NPI number — TRISTAN GLENN KELLER LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
TRISTAN
Provider Middle Name:
GLENN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1053346171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 BOULDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87301-5795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-863-3604
Provider Business Mailing Address Fax Number:
505-863-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 E AZTEC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-863-3828
Provider Business Practice Location Address Fax Number:
505-863-6612
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-05565 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50526 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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