Provider Demographics
NPI:1144773854
Name:KELLER, ALEXANDER GAVIN
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GAVIN
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10050 E HARVARD AVE APT B416
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-6634
Mailing Address - Country:US
Mailing Address - Phone:214-650-8246
Mailing Address - Fax:
Practice Address - Street 1:10050 E HARVARD AVE APT B416
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-6634
Practice Address - Country:US
Practice Address - Phone:214-650-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38580736873Medicaid