1427158310 NPI number — DR. AUTUMN RENEE KELLER DC

Table of content: DR. AUTUMN RENEE KELLER DC (NPI 1427158310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427158310 NPI number — DR. AUTUMN RENEE KELLER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
AUTUMN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONATI
Provider Other First Name:
AUTUMN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427158310
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:
813 TAPPAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43537-3557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-887-1531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
659 E BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43605-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-698-2008
Provider Business Practice Location Address Fax Number:
419-698-2640
Provider Enumeration Date:
09/22/2006

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: 111N00000X , with the licence number:  3204 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4066521 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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