Provider Demographics
NPI:1144385196
Name:KELLER, JEFFREY I (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:I
Last Name:KELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3258
Practice Address - Country:US
Practice Address - Phone:781-485-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2403111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45739Medicare ID - Type Unspecified