1255716643 NPI number — SAMUEL KELLER

Table of content: SAMUEL KELLER (NPI 1255716643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255716643 NPI number — SAMUEL KELLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
SAMUEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1255716643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5332 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROELAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66205-2217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-543-1970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5332 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROELAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66205-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-543-1970
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2015

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: 237700000X , with the licence number:  2017032373 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: KS1615 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: KS1615 . This is a "HEARING AID DISPENSER LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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