1437955689 NPI number — MR. SAMUEL RAY KELLER PEER SUPPORT

Table of content: MR. SAMUEL RAY KELLER PEER SUPPORT (NPI 1437955689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437955689 NPI number — MR. SAMUEL RAY KELLER PEER SUPPORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
SAMUEL
Provider Middle Name:
RAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PEER SUPPORT
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:
1437955689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
964 SE TERRACE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470-4330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-533-9377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1939 NE DIAMOND LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97470-3573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-957-5646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2025

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: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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