Provider Demographics
NPI:1275307209
Name:KELLER, PRESTON TANNER
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:TANNER
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 1:10580 MOUNTAIN VIEW AVE APT K
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8415
Mailing Address - Country:US
Mailing Address - Phone:208-965-6897
Mailing Address - Fax:
Practice Address - Street 1:11130 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1729
Practice Address - Country:US
Practice Address - Phone:909-558-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program