1366505612 NPI number — MR. PHELO JOSEPH KELLER OTSC

Table of content: MR. PHELO JOSEPH KELLER OTSC (NPI 1366505612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366505612 NPI number — MR. PHELO JOSEPH KELLER OTSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
PHELO
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTSC
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:
1366505612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2375
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGAN CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-384-7900
Provider Business Mailing Address Fax Number:
985-384-8049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 LAKEWOOD DR SUITE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGAN CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-384-7900
Provider Business Practice Location Address Fax Number:
985-384-8049
Provider Enumeration Date:
12/18/2006

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: 246Z00000X , with the licence number:  NBCOT981110 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 950290 . This is a "OTC NATIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 981110 . This is a "NBCOT" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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